Every finding on record at Good Samaritan Living Center

Based on record review and interview, the facility failed to electronically submit payroll based staffing information for direct care staff as required. The deficient practice had the potential to affect the 48 residents residing in the facility.Findings: Review of the facility's policy titled Reporting Direct Care Staffing Information (Payroll-Based Journal) revealed in part: 1. Complete and accurate direct care staffing information is reported electronically to CMS through the Payroll-Based Journal (PBJ) system in a uniform format specified by CMS. 7. Data is submitted only by designated personnel with training on the PBJ user interface. 8. Technical specifications for uploading data directly from payroll or time and attendance system will be accessed through: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html. 12. Definitions, instructions and examples of the PBJ user interface can be found in the CMS' Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual. Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 1 2026 (October 1, 2025 through December 31, 2025) revealed, in part: the facility failed to submit staffing data for the quarter, as evidenced by being triggered for 5 out of 5 possible staffing metrics. Review of the facility's document titled CMS Submission Report PBJ Final File Validation Report revealed a submission date of 03/26/2026. The document showed submission is selected for fiscal quarter 2 (instead of quarter 1). Further review revealed all submitted staffing data for quarter 1 fiscal year 2026 was rejected and showing no data present at this time. Rejection status for this quarter revealed an error which read Unable to process record: Quarter/fiscal year do not match user selection. Cause: Reporting period selected on upload screen does not match submitted file. Action: Review selections to ensure information consistency. On 05/12/2026 at 10:45 a.m. an interview was conducted with S2AIT. She stated she was responsible for PBJ submission each quarter. She stated she was unaware the submission had been rejected and was unaware of how to run the validation report prior this interview. She reviewed the PBJ Validation report for quarter 1 fiscal year 2026. She confirmed the submission was rejected for quarter 1. On 05/12/2026 at 3:22 p.m. an interview was conducted with S1ADMIN. He confirmed S2AIT was responsible for submitting PBJ data. He confirmed the facility's PBJ rejection status for quarter 1 fiscal year 2026.

Based on observations, interviews, and record review, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure staff:1. Properly utilized EBP PPE during high contact resident care activities for 2 (#2 and #38) of 3 residents observed and required EBP; and 2. Properly dispose of soiled linens after bed linen change and remove soiled PPE prior to exiting a resident's room for 1 (#38) of 3 resident observed receiving ADL care.1. Resident #2 Review of the Clinical Record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included pressure ulcer of sacral region, stage 4. Review of Resident #2's current Physician Orders revealed the following, in part: Enhanced Barrier Precautions every day and night shift. Review of Resident #2's current Care Plan revealed the following, in part: Problem: Pressure ulcer to sacrum stage 4. Intervention: EBP per policy due to wound. An observation was made on 05/11/2026 at 8:42 a.m. of the entry to Resident #2's room. A name plate was located near Resident #2's door with a red triangle next to the resident's name. An observation was made on 05/12/2026 at 10:30 a.m. of S5CNA providing incontinence care for Resident #2 without a gown. An interview was conducted on 05/12/2026 at 11:07 a.m. with S5CNA. S5CNA stated the red triangle on Resident #2's name plate indicated EBP which meant to wear a gown and gloves when direct care was provided for the resident. S5CNA confirmed she did not wear a gown while she provided perineal care to Resident #2 and should have because she had a wound which required EBP. An observation was made on 05/13/2026 at 8:10 a.m. of S10LPN performing wound care for Resident #2 without a gown. An interview was conducted on 05/13/2026 at 8:45 a.m. with S10LPN. She stated a red triangle on a resident's door name plate indicated the resident required EBP. She stated EBP consisted of wearing a gown and gloves during wound care and any direct care for that resident. She stated she should have worn a gown during Resident #2's wound care and did not. Resident #38 Review of the Clinical Record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses which included infection of the skin and subcutaneous tissue. Further review revealed Resident #38 had a colostomy, a wound to the sacrum and a suprapubic catheter. Review of Resident #38's current Physician Orders revealed the following, in part: Enhanced Barrier Precautions every day and night shift. Review of Resident #38's current Care Plan revealed the following, in part: Problem: Moisture Associated Skin Damage (MASD) to sacrum-04/19/2026-wound infection (Osteomyelitis). Problem: I am at risk for developing multiple drug resistant organism infections related to: suprapubic indwelling urinary catheter, colostomy, and wounds. Intervention: Enhanced Barrier Precautions An observation was made on 05/13/2026 at 10:39 a.m. of the entry to Resident #38's room. A name plate was located near Resident #38's door with a red triangle next to the resident's name.An observation was made on 05/13/2026 at 10:40 a.m. of S6LPN and S7CNA providing colostomy bag care for Resident #38 without gowns. An interview was conducted on 05/13/2026 at 10:45 a.m. with S6LPN. She stated she was providing direct care to Resident #38's colostomy bag without a gown. S6LPN confirmed Resident #38 was on EBP. She stated she should have worn a gown to ensure all enhanced barrier precautions were followed and did not. An interview was conducted on 05/13/2026 at 10:46 a.m. with S7CNA. She stated she was assisting S6LPN perform care to colostomy on Resident #38. S7CNA confirmed she did not wear a gown while assisting with direct care. S7CNA stated she was unaware she needed to wear a gown while providing direct care to Resident #38. S7CNA donned a gown at this time and resumed direct care to Resident #38. 2. An observation was made on 05/13/2026 at 11:00 a.m. of S7CNA exiting Resident #38's room wearing a gown and gloves holding soiled linens. S7CNA then walked down the hall with the soiled bed linens not contained in a bag to the laundry room. An interview was conducted on 05/13/2026 at 11:05 a.m. with S7CNA. She stated after assisting S6LPN with colostomy care, she changed Resident #38's feces soiled bed linens. She confirmed she removed the linens from the bed then transported linen to the shower room while wearing the soiled gown and gloves, without bagging the linen. S7CNA stated she didn't have a bag in the room to place the soiled linen inside. S7CNA confirmed the soiled linens should have been placed in a bag prior to transporting to shower room and did not. An interview was conducted on 05/13/2026 at 3:30 p.m. with S3DON. S3DON confirmed she would expect all staff to follow and implement Enhanced Barrier Precautions when direct care was provided for Residents on EBP. S3DON confirmed she would expect staff to bag soiled linen and remove personal protective equipment to exiting room.

Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status. The facility failed to ensure staff accurately coded the correct discharge location for 1 (#55) of 1 resident reviewed for closed record.Review of Resident #55's Discharge Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 03/26/2026 revealed Resident #55 was discharged to home/community.Review of Resident #55's Nurse's Notes revealed the following, in part:03/26/2026 Resident discharged today with home health services.An interview was conducted on 05/13/2026 at 3:15 p.m. with S11MDS. S11MDS confirmed Resident #55 discharged home with home health services. S11MDS reviewed Resident #55's Discharge MDS with an ARD of 03/26/2026. S11MDS confirmed the discharge status should have been coded accurately for discharge to home under care of organized home health service organization and it was not.An interview was conducted on 05/13/2026 at 3:16 p.m. with S3DON. S3DON stated she expected all discharge assessments to accurately reflect each residents' discharge status.

Based on observations, record reviews, and interviews, the facility's staff failed to implement pressure ulcer prevention interventions per physician orders and plan of care for 1 (#2) of 2 sampled residents with pressure ulcers.Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included Pressure Ulcer of Sacral Region Stage 4. Further review revealed she had limited bed mobility. Review of Resident #2's current Physician Orders revealed the following, in part:Wound Prevention: Ensure bilateral heel boots are in place at all times, every day and night shift. Review of Resident #2's current Plan of Care revealed the following, in part:Problem:Potential for risk of skin breakdown related to decreased mobility.Intervention:Ensure heel protector boots are applied to bilateral feet at all times when in bed. Review of the Nursing Note dated 05/13/2026 at 12:59 p.m. revealed the following, in part: Reported redness to right heel and resident's right heel boot not in place. Assessed resident's right heel and noted some scarring and redness, with blanchable redness. An observation was made on 05/12/2026 at 10:30 a.m. of S5CNA providing incontinence care for Resident #2. Resident #2 was lying in bed with a heel boot on the left foot, and no heel boot on the right foot. S5CNA searched Resident #2's room for the missing heel boot and exited her room. An interview was conducted on 05/12/2026 at 11:07 a.m. with S5CNA. S5CNA confirmed Resident #2 had a heel boot on the left foot and not on the right foot. S5CNA further confirmed Resident #2's care plan stated she should have a heel boot on both feet. S5CNA confirmed after she searched Resident #2's room, she could not find the other heel boot to place on the right foot and would find another heel boot. An observation was made on 05/13/2026 at 8:10 a.m. of S10LPN conducting sacral wound care for Resident #2 in her room. Resident #2 had a heel boot on the left foot and not on the right foot.An observation was made on 05/13/2026 at 11:45 a.m. of S8LPN assessing Resident #2. Resident #2 was lying in the bed and had a heel boot located on the left foot and not on the right foot. S8LPN assessed Resident #2's right heel. Resident #2's right heel had a small, red, blanchable spot. S8LPN searched Resident #2's room for the heel boot and exited her room. An interview was conducted on 05/13/2026 at 11:46 a.m. with S8LPN. S8LPN confirmed Resident #2's right foot did not have a heel boot. S8LPN stated she reviewed Resident #2's physician orders and confirmed Resident #2 should have heel boots on bilateral heels at all times while in the bed to prevent pressure ulcers. S8LPN confirmed during her assessment, she identified blanchable redness on the right heel. S8LPN confirmed after she searched Resident #2's room, she could not find the heel boot and retrieved another heel boot and applied to the right foot.An interview was conducted on 05/13/2026 at 2:59 p.m. with S3DON. S3DON stated Resident #2 was at high risk for heel pressure ulcers. S3DON reviewed physician orders and confirmed Resident #2's physician order to ensure bilateral heel boots were placed at all times while in the bed. S3DON stated she expected the nurses to monitor and replace heel boots as needed to prevent pressure ulcers. She stated if S5CNA identified Resident #2's heel boot was not on the right foot, she should have replaced the heel boot immediately and notified the nurse.

Based on interviews and record reviews, the facility failed to ensure a resident's Minimum Data Set accurately reflected their status for 1 (#3) of 5 residents in the sample. The facility failed to ensure Resident #3 was coded correctly for Urinary Tract Infection in the last 30 days.Review of Resident #3's Clinical Record revealed an admission date of 06/26/2025 with diagnoses, which included Cerebral Infarction, Urinary Tract Infection, Aphasia following Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction.Review of Resident #3's Significant Change Minimum Data Set with an Assessment Reference Date of 10/31/2025 revealed the following in part:Section I-Active Diagnoses:Infections:I2300. Urinary Tract Infections (last 30 days): No Review of Resident #3's latest Care Plan revealed the following in part:Focus: history/diagnosis Urinary Tract Infection 07/01/2025 diagnosis Urinary Tract Infection 10/15/2025 hospital return diagnosis Urinary Tract Infection.Interventions: Administer medications per physician orders: assist with pericare after incidents of incontinence, instruct resident and staff on proper cleaning of perineal area after voiding or bowel movement, labs per physician orders, report abnormal to physician, monitor fluid intake and make sure resident is well hydrated, observe for signs and symptoms of Urinary Tract Infection: foul odor urine, burning on urination, bladder distention, frequent voiding, sediment in urine. Review of Resident #3's hospital discharge paperwork dated 10/13/2025-10/15/2025 revealed Resident #3 had a Urinary Tract Infection associated with indwelling urethral catheter listed as a final active diagnosis dated 10/14/2025. On 01/07/2026 at 1:30 p.m., an interview was conducted with S2LPN. S2LPN confirmed Resident #3 was discharged from the local hospital on [DATE] with a diagnosis, which included Urinary Tract Infection. S2LPN further confirmed a Significant Change Minimum Data Set was completed on 10/31/2025 and should have been accurately coded to reflect a Urinary Tract Infection within the last 30 days, and was not. On 01/07/2026 at 2:00 p.m., an interview was conducted with S1DON. S1DON confirmed she expected a resident's Minimum Data Set to accurately reflect a Urinary Tract Infection on the Significant Change Minimum Data Set. She confirmed Resident #3's Significant Change Minimum Data Set, dated [DATE] did not accurately reflect that.

47173 Based on record review, observations, and interviews, the facility failed to ensure services were provided to meet quality professional standards by failing to: 1. Transcribe physician's orders accurately for 1 (#2) of 5 (#2, #14, #18, #34, and #36) residents reviewed for medication administration; and 2. Follow physician orders for 1 (#9) of 12 residents reviewed in the final sample. Findings: 1. Review of the facility's policy titled, Medication and Treatment Orders dated July 2016, revealed the following in part: Policy Statement Orders for medication and treatments will be consistent with principles of safe and effective order writing. Policy Interpretation and Implementation 9. Orders for medication must include: c. dosage and frequency of administration Review of Resident #2's clinical record revealed he was admitted to the facility on [DATE] with diagnoses, which included Pneumonia. Review of Resident #2's physician's orders in the Electronic Health Record (EHR) revealed the following: Start date 05/06/2025 - Ceftriaxone Sodium Injection Solution Reconstituted 2 grams. Use 2 grams intravenously (IV) two times a day related to Pneumonia for 10 days. On 05/13/2025 at 10:10 a.m., an observation was made of S4LPN preparing to administer an IV antibiotic to Resident #2. An observation was made of the label on the IV bag. The label read the following: Ceftriaxone 2 grams IV @ 100 ml/hr every 12 hours x 10 days. On 05/13/2025 at 1:11 p.m., an interview was conducted with S3ADON. She stated Resident #2 returned from the hospital on 05/06/2025 with an order for Ceftriaxone 2 grams IV. She stated S5LPN modified the order in the Electronic Health Chart and did not include a rate at which the antibiotic should have been infused. S3ADON stated she was responsible for reviewing the physician's orders and must have missed the error. She confirmed the rate of the IV antibiotic was part of the medication order and should have been entered in the Electronic Health Chart to reflect the full and correct order and was not. On 05/13/2025 at 3:52 p.m., an interview was conducted with S5LPN. She stated she recalled Resident #2 returned from the hospital on 05/06/2025 with new orders. She stated she contacted Resident #2's physician to verify if it was okay to proceed with all new orders. She stated she forgot to clarify the rate of the Ceftriaxone 2 grams IV and should have. She stated she did not place a rate for the IV antibiotic in the Electronic Health Chart and should have. On 05/13/2025 at 1:15 p.m., an interview was conducted with S2DON. She reviewed Resident #2's Electronic Health Chart and stated he had an order placed for Ceftriaxone 2 grams IV twice a day. She verified and confirmed the IV antibiotic order did not consist of a rate and should have. 2. Review of Resident #9's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included Gastrostomy. Review of Resident #9's physician's orders in the Electronic Health Record (EHR) revealed the following: Start date 05/05/2025 - Singulair Oral Tablet 10 mg, give 10 mg by mouth one time a day. Start date 04/02/2025 - Sodium Bicarbonate Oral Tablet 650 mg, give 650 mg by mouth one time a day. Review of Resident #9's Medication Administration Record dated May 2025 revealed the following: Singulair Oral Tablet 10 mg, give 10 mg by mouth one time a day. Administered at 5:00 a.m. by S8LPN on 05/12/2025 and 05/13/2025. Sodium Bicarbonate Oral Tablet 650 mg, give 650 mg by mouth one time a day. Administered at 5:00 a.m. by S8LPN on 05/12/2025 and 05/13/2025. On 05/13/2025 at 4:30 p.m., an interview was conducted with S8LPN. She stated she administered Singulair and Sodium Bicarbonate to Resident #9 via PEG tube on 05/12/2025 and 05/13/2025. She stated she was aware Singulair and Sodium Bicarbonate physician orders stated to give by mouth, however she gave the two medications via PEG tube with Resident #9's other 5:00 a.m. medications. On 05/14/2025 at 9:30 a.m., an interview was conducted with S2DON. She reviewed Resident #9's current physician orders and Medication Administration Record for May 2025. She confirmed Resident #9's physician orders for Singulair and Sodium Bicarbonate stated to give by mouth and were being given via PEG tube.

Based on observations and interviews, the facility failed to store food under sanitary conditions by failing to ensure food was properly labeled and stored in unit refrigerators. This deficient practice had the potential to affect 40 residents who were able to store and consume food in the facility's unit refrigerator. Findings: Review of the facility's policy titled Use and Storage of Food Brought in by Family or Visitors, undated, revealed the following, in part: Policy Explanation and Compliance Guidelines: 2. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated. On 05/12/2025 at 12:15 p.m., an observation was made of the residents' unit refrigerator which contained the following items: 2 brown paper bags containing food items with no date; and 2 small to-go Styrofoam boxes containing food items with no date. The freezer contained the following items: 1 pint of ice cream with no name or date; and 1 gallon of ice cream with no name or date. On 05/12/2025 at 12:19 p.m., an interview was conducted with S2DON. She stated staff should label all outside food items with the resident's name and a date when stored in the residents' unit refrigerator. S2DON observed and confirmed the above mentioned items were not properly labeled and should have been. On 05/13/2025 at 3:00 p.m., an interview was conducted with S1ADM. S1ADM was made aware of the above named food items stored in the residents' unit refrigerator with no name and date. He confirmed all outside food brought into the facility and stored in the residents' unit refrigerator, should be labeled with a name and date.

Based on record reviews and interviews, the facility failed to ensure all medical records regarding the resident's code status reflected the resident's wishes for 1 (#14) of 16 residents reviewed in the initial screening for advanced directives. Findings: Review of Resident #14's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #14's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a BIMS (Brief Interview for Mental Status) of 15, indicating he was cognitively intact. Review of Resident #14's Lousiana Physician Orders for Scope of Treatment (LaPOST) in physical hard chart, dated [DATE], revealed the following, in part: Cardiopulmonary Resuscitation (CPR): Box checked-DNR/Do not attempt Resuscitation Signed by Resident #14. Review of Resident #14's [DATE] Physician Orders revealed: [DATE] DNR (Do Not Resuscitate) Review of Resident #14's Care Plan dated [DATE] revealed the following, in part: Problem: Resident #14 had a LaPOST related to wishes to be a DNR. Review of Resident #14's physical hard chart revealed Resident #14 had two charts. Resident #14's physical hard chart #1 indicated he was a Full Code and physical hard chart #2 indicated he was a DNR. On [DATE] at 9:56 a.m., an interview was conducted with S7WC. S7WC stated she is responsible for constructing the charts, including placement of Full Code or DNR stickers on the outside of the charts. She verified the information for the stickers was taken from the [NAME] Record Worksheet and the admission orders. She stated the code status is listed on the Admission Record Worksheet. She stated it was her responsibility to update chart code status. S7WC reviewed Resident 14's chart #1 and chart #2. S7WC confirmed chart #1 had a sticker indicating he was Full Code and chart #2 had a sticker indicating he was a DNR. She confirmed chart #1 was incorrect and should have been updated. On [DATE] at 3:06 p.m., an interview was conducted with S4LPN. She stated in the event of an emergency she would refer to the LaPOST to determine a resident's code status. S4LPN confirmed Resident #14's physical hard chart #1 indicated he was a Full Code and physical hard chart #2 indicated he was a DNR. She stated she would have followed Resident #14's LaPOST, and not perform CPR. On [DATE] at 3:14 p.m., an interview was conducted with S6LPN. S6LPN stated in the event of an emergency she would refer to the LaPOST to determine a resident's code status. S6LPN confirmed Resident #14's LaPOST indicated he was a DNR. She stated she would have followed Resident #14's LaPOST, and not perform CPR. On [DATE] at 10:12 a.m., an interview was conducted with S3ADON. S3ADON confirmed Resident #14 had two physical hard charts. She reviewed both of Resident 14's chart #1 and chart #2. S3ADON confirmed chart #1 had a Full Code sticker and chart #2 had a DNR sticker. She confirmed chart #1 was incorrect and needed updating. She confirmed the incorrect stickers could cause confusion during an emergency. On [DATE] at 3:11 p.m., an interview was conducted with S2DON. S2DON confirmed Resident #14's LaPOST revealed he was a DNR, and the electronic health record reflected he was a DNR. S2DON stated the physical hard chart was not updated with Resident #14's most recent code status wishes and should have been. S2DON confirmed the LaPOST and the physical hard chart should match to accurately reflect the resident's end of life wishes and did not. S2DON stated she would expect nursing staff to look in the resident's chart for the LaPOST for resident's current code status.

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure: 1. S6CNA wore proper Personal Protective Equipment (PPE) while providing care for Resident #15 who was on Enhanced Barrier Precautions (EBPs); and 2. S4LPN used appropriate hand hygiene between administering medications to 5 (#1, #3, #5, #16 and #29) of 5 (#1, #3, #5, #16 and #29) resident's observed during medication pass. Findings: 1. Review of the facility's policy dated 08/2022, titled, Enhanced Barrier Precautions, revealed, in part: 1. Enhanced barrier precautions (EBPs) are used as an infection control intervention to reduce the spread of multi-drug resistant organisms to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include: c. transferring d. providing hygiene f. changing briefs or assisting with toileting 5. EBPs are indicated .for residents with wounds . regardless of Multidrug Resistant Organism colonization. 6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound . 9. Staff are trained prior to caring for residents on EBPs. Review of the Clinical Record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included Pressure Ulcer of Left Heel Stage 3. On 04/11/2024 at 9:40 a.m., an observation was made of Resident #15. S6CNA transferred the resident from the wheelchair to the toilet using a stand-up lift. S6CNA did not have a gown on during the transfer. On 04/11/2024 at 9:45 a.m., an interview was conducted with S6CNA. She stated Resident #15 was not on EBPs. She confirmed she did not use a gown during the transfer. On 04/11/2024 at 11:42 a.m., an interview was conducted with S3ADON. She stated Resident #15 was on EBPs because of her stage 3 heel wound. She stated the process for residents on EBP was to don gloves and gown for any kind of direct contact care for the residents. She confirmed transferring a resident to the toilet was considered direct contact care. On 04/11/2024 at 2:27 p.m., an interview was conducted with S2DON. She stated Resident #15 had an active stage 3 wound on her heel and was on EBPs for direct contact care of the resident. She stated nursing staff should wear gloves and a gown when transferring Resident #15 from the wheelchair to the toilet. 2. Review of the facility's policy revised on 08/2015 titled, Handwashing/Hand Hygiene, revealed, in part: This facility considers hand hygiene the primary means to prevent the spread of infections. 7. Use an alcohol-based hand rub .for the following situations: . b. Before and after direct contact with residents. c. Before preparing or handling medications . Review of the facility's policy revised on 04/2019 titled, Administering Medications, revealed, in part: 25. Staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves .) for the administration of medications . On 04/09/2024 at 8:20 a.m., an observation was made of S4LPN during medication administration. S4LPN did not use hand sanitizer or wash hands after administering medication to Resident #16 and before medication preparation for Resident #1. Further observation revealed S4LPN did not use hand sanitizer or wash hands in the hallway or the room before, during and after administering medication to Resident #1. On 04/09/2024 at 8:22 a.m., an observation was made of S4LPN preparing medication's for administration to Resident #5. S4LPN entered Resident #5's room, administered the medication's to the resident by handing a cup of pills to Resident #5 to take by mouth. S4LPN exited the room without performing hand hygiene. On 04/09/2024 at 8:27 a.m., an observation was made of S4LPN preparing medication's for administration to Resident #3. S4LPN entered Resident #3's room, administered the medication's to the resident by handing a cup of pills to Resident #3 to take by mouth. S4LPN exited the room without performing hand hygiene. On 04/09/2024 at 8:30 a.m., an observation was made of S4LPN not using hand sanitizer or washing hands before preparation of medication for Resident #29. On 04/09/24 at 8:45 a.m., an interview was conducted with S4LPN. She confirmed she did not use hand sanitizer or wash her hands before or after medication administration in between Residents #1, #3, #5, and #16 and before medication administration for Resident #29. On 04/09/24 at 2:28 p.m., an interview was conducted with S2DON. She stated during medication administration she expected the nurses to sanitize or wash hands before the nurse entered residents' rooms and after they exited residents' rooms.

Based on observations, interviews, and record review, the facility failed to ensure that the food items served from the menu met the resident's personal dietary choices for 1 (#15) of 16 sampled residents reviewed in the initial pool. Findings: Review of the Clinical Record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included Anorexia, Irritable bowel syndrome with Constipation, Gastro-esophageal Reflux Disease without Esophagitis, Vitamin Deficiency, Nausea, and Dysphagia. Review of the Quarterly MDS with an ARD of 02/02/2024 revealed Resident #15 had a BIMS of 15, which indicated she was cognitively intact. On 04/07/2024 at 10:32 a.m., an interview was conducted with Resident #15. She stated the rice served at the facility was not good. She stated she would prefer mashed potatoes every day, but the facility did not accommodate her preference. She stated she told S7DM about her preferences a while ago, but she was still receiving rice, which was not her preference. On 04/08/2024 at 11:59 a.m., an observation was made of Resident #15's lunch tray. Her lunch tray consisted of a pork chop with rice and gravy, cornbread and okra. Resident #15 ate 0% of lunch. On 04/08/2024 at 12:01 p.m., an interview was conducted with Resident #15. She stated she did not touch her tray today because she did not like the rice. She stated she had previously told S7DM of her preferences not to be served rice, and she would prefer mashed potatoes. She stated she did not tell the CNA today because she had already informed staff and it never changed. At this time, an observation of Resident #15's meal ticket revealed dislikes, which included rice. Further review revealed special notes which included will eat potato salad and cheesy potatoes. On 04/09/2024 at 11:44 a.m., an observation of Resident #15's lunch tray revealed chicken and dumplings with rice. Resident #15 ate 10% of her lunch tray. On 04/09/24 at 11:51 a.m., an interview was conducted with S9CNA. She stated she picked up Resident #15's tray for lunch today, and Resident #15 requested a substitute. She stated she told Resident #15 the substitute was bell peppers, and Resident #15 stated she did not want the substitute. She stated she did not offer Resident #15 anything else as a substitute to accommodate her preferences. On 04/09/2024 2:22 p.m., an interview was conducted with S7DM. She was made aware of the observations of Resident #15's meal tickets for lunch on 04/08/2024 and 04/09/2024 and the food Resident #15 was served. She stated according to the meal tickets for Resident #15, rice should not have been served on her tray and another preferred substitute should have been provided. On 04/11/2024 at 2:49 p.m., an interview was conducted with S1ADM. He stated he would expect staff to honor resident food preferences for their likes and dislikes. He stated if the likes and dislikes are on the meal ticket and the resident received a dislike on their tray it would not be acceptable.

Based on interviews and record review, the facility failed to employ staff with appropriate competencies and skills sets to carry out the functions of the food and nutrition service by failing to have a certified dietary manager on staff. Findings: Review of S7DM's food service management and safety certification revealed an expiration date of [DATE]. On [DATE] at 10:03 a.m., an interview was conducted with S7DM. S7DM stated her food service management and safety certification expired on [DATE]. She stated she or any other staff in the facility did not have a certificate or degree for food service or dietary management. On [DATE] at 10:50 a.m., an interview was conducted with S1ADM. He stated he realized today S7DM's food service management and safety certification had expired. He stated he or any other staff in the facility did not have a certificate or degree for food service or dietary management.

48184 Based on record reviews and interviews, the facility failed to ensure Resident #1's significant change in condition was communicated to the physician after having a fall with head injury for 1 (#1) of 4 (#1, #2, #3, and #R5) residents reviewed for notification of change. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a cognitively intact resident without confusion, on [DATE] at 7:46 a.m., when the resident returned from the emergency room after a fall and exhibited new onset signs of confusion. Nursing staff verbalized and documented Resident #1's increased confusion from [DATE] through [DATE] and failed to identify the change as a potential for head injury, implement new interventions, or notify the physician. On [DATE] at 5:00 a.m., Resident #1 fell and was transported to the emergency room where CT scan revealed a large Acute on Chronic Subdural bleed. Resident #1 expired on [DATE] at 10:19 a.m. S1ADM was notified of the Immediate Jeopardy situation on [DATE] at 7:30 p.m. The Immediate Jeopardy was removed on [DATE] at 5:12 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at a potential for more than minimal harm for the other 38 residents who resided in the facility and had the potential for a change in condition. Findings: Review of the facility's Change in Resident's Condition or Status policy revealed the following, in part: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation 1. The nurse will notify the resident's Attending Physician or physician on call when there has been (an): d. Significant change in the resident's physical/emotional/mental condition; i. Specific instruction to notify the Physician of changes in the resident condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a.Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) Review of the facility's Routine Resident Checks policy revealed the following, in part: Policy Statement: Staff shall make routine resident checks to help maintain resident safety and well-being. Policy Interpretations and Implementation 3. The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident's condition. Review of the facility's Falls- Clinical Protocol procedure revealed the following, in part: Assessment and Recognition Monitoring and Follow- Up 1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as a late fracture or subdural hematoma have been ruled out or resolved. a. Delayed complication such as while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. Review of the facility's Acute Condition Changes- Clinical Protocol procedure revealed the following, in part: 2. Direct Care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident and how to communicate these to the nurse. A review of the clinical records revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included, Other Lack of Coordination; Muscle Weakness; Age Related Physical Disability; Repeated Falls; Difficulty in Walking; Muscle Wasting and Atrophy; Myasthenia Gravis, Without Exacerbation; Myalgia; Unsteadiness on Feet; Abnormalities of Gait and Mobility; Tremor. A review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 15, which indicated Resident #1 was cognitively intact. Review of Resident #1's Nurse's Notes dated [DATE] revealed at 8:00 p.m. Resident #1 was alert, awake, and oriented times 3. Signed by S16LPN. Review of Resident #1's Nurse's Note dated [DATE] revealed at 2:31 a.m. Resident #1 fell , hematoma noted to left side of forehead. Signed by S14LPN. A review of the emergency room Report dated [DATE] revealed Resident #1 presented to the emergency room following a fall. The ER physician documented Resident #1 was alert and oriented to person, place, time and situation. Normal sensory, motor, speech and coordination was observed. Resident #1 was discharged back to the nursing facility with education concerning adult head injuries and when to get help. A review of the emergency room discharge education from [DATE] titled Head Injury, Adult revealed to get help right away if: you have a very bad headache, weakness in your arms/legs, more confusion or more grumpy moods, your symptoms get worse, you are sleepier than normal, you lose your balance or your speech is slurred. The education stated, Do not wait to see if symptoms go away. Get medical help right away. Review of Resident #1's Nurse's Notes dated [DATE] revealed the following, in part: [DATE] at 7:46 a.m. Resident #1 returned from hospital, awake but confused. Signed by S6LPN. A review of Resident #1's Neurological Assessments dated [DATE] revealed the following: [DATE] at 8:30 a.m., Resident #1's speech was unclear, unable to grasp hands and was disoriented but conversed. [DATE] at 9:30 a.m., Resident #1 continued to be disoriented and unable to grasp hands. [DATE] at 9:00 p.m. Resident has been lethargic/sleepy and unable to take pain medication. Oriented x2, confused. Signed by S14LPN. [DATE] at 11:49 a.m. Physical Therapy reported resident is more confused than the morning and also from the previous Friday when assessed. Signed by S5LPN. [DATE] at 8:00 p.m. Resident has been lethargic and sleepy and unable to take pain medication. Resident is oriented X2 and confused. Signed by S14LPN. Review of Resident #1's Physical Therapy notes dated [DATE] revealed the following: [DATE], Resident #1 refused to get out of bed due to feeling very weak. Nursing notified. Signed by S7PTA. [DATE], Resident #1 presented with continued confusion and nursing notified. Resident refused to get out of bed. Signed by S7PTA. Review of Resident #1's Nurse's Note dated [DATE] revealed at 5:00 a.m. Heard yelling and found Resident #1 on floor between bed and window. Assessed resident and noticed a golf ball sized knot to back of her head. Alert and oriented x 2 with intermittent confusion. Signed by S14LPN. A review of the emergency room Report dated [DATE] revealed Resident #1 presented to the emergency room at 6:09 a.m. following a fall at the nursing facility. A CT scan of the head was performed and revealed a large acute on chronic subdural hematoma causing a mass effect and a midline shift. Resident #1 was found without respirations at 7:31 a.m. and the time of death was pronounced at 10:19 a.m. A review of the Physician Communication Fax Sheets dated from [DATE] through [DATE] revealed no records of any communication faxed to Resident #1's physician regarding Resident #1's change in status. On [DATE] at 11:36 a.m., an interview was conducted with S14LPN. She stated Resident #1 fell on [DATE], hit her head, and was sent to the ER. She stated prior to her fall she was alert and oriented x 3. She stated Resident #1 started to become confused after her return from the ER. She confirmed Resident #1 had a change in condition after a fall, but did not notify the MD because she worked night shifts. She stated the nursing staff were all aware of Resident #1's new onset confusion after the fall on [DATE]. On [DATE] at 4:35 p.m., an interview was conducted with S3LPN/UM. She stated for neurological changes, staff should notify the doctor. She stated Resident #1 was Awake Alert and Oriented x 3 and had a BIMS of 15 upon admit in [DATE]. She stated when Resident #1 returned confused from hospital on [DATE], staff should have notified the doctor. On [DATE] at 8:59 a.m., an interview was conducted with S6LPN. She stated on [DATE] Resident #1 returned from the hospital confused and disoriented. She stated this was not Resident #1's normal mental status. She stated while taking care of Resident#1 she did not realize she was exhibiting symptoms of a head injury, but should have notified the doctor and did not. On [DATE] at 9:25 a.m., an interview was conducted with S10MD. He stated he last assessed Resident #1 on [DATE] and her mental status was alert and oriented with no confusion. He stated nursing staff did not notify him of Resident #1's new onset of confusion after returning from theER on [DATE]. He stated the nurse should have notified him of Resident #1's change in mental status and he would have sent Resident #1 back to the ER for another evaluation. He stated he would have considered this a significant change which he should be notified for. He confirmed a CT result reading Acute on Chronic Subdural Hematoma meant there was some blood present which had worsened. He confirmed no notifications of Resident #1's change was conveyed to him at any time from [DATE] through [DATE] and should have. On [DATE] at 1:25 p.m., an interview was conducted with S5LPN. She stated on a day-to-day basis Resident #1 was very alert and able to hold a conversation. She stated Physical Therapy made her aware Resident #1 was more confused on [DATE]. She stated she was aware of the signs and symptoms of a brain bleed following a head injury. She stated after her assessment of Resident #1 she used her nursing judgment and did not call the doctor. On [DATE] at 4:47 p.m. an interview was conducted S4PADON. She stated she was aware of Resident#1's falls on [DATE] and [DATE]. She stated she was not made aware of a significant change of Resident #1's mental status. She stated if Resident #1 returned from the emergency room confused, she would have considered it to be a significant change and the MD should have been notified. On [DATE] at 2:31 p.m., an interview was conducted with S1ADM. He stated Resident #1 was admitted to the facility with a BIMS of 15. S1ADM stated he was not aware Resident #1 returned [DATE] with increased confusion and was also not aware Resident #1's physician was not notified of this change. He confirmed the physician should have been notified when the change was identified by the nursing staff. On [DATE] at 4:39 p.m. an interview was conducted with S2DON. She stated it was the nurse's responsibility to report changes in a resident's conditions to the physician and to the DON. The DON would then report changes in resident conditions to the administrator.

48184 Based on record reviews and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility failed to ensure a system was in place for nursing staff to identify, intervene and communicate a change of condition in Resident #1. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a cognitively intact resident without confusion, on [DATE] at 7:46 a.m., when the resident returned from the emergency room after a fall and exhibited new onset signs of confusion. Nursing staff verbalized and documented Resident #1's increased confusion from [DATE] through [DATE] and failed to identify the change as a potential for head injury, implement new interventions, or notify the physician. On [DATE] at 5:00 a.m., Resident #1 fell and was transported to the emergency room where CT scan revealed a large Acute on Chronic Subdural bleed. Resident #1 expired on [DATE] at 10:19 a.m. S1ADM was notified of the Immediate Jeopardy situation on [DATE] at 7:30 p.m. The Immediate Jeopardy was removed on [DATE] at 5:12 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at a potential for more than minimal harm for the other 38 residents residing in the facility. Findings: Cross Reference F684 Cross Reference F580 Review of the facility's Routine Resident Checks policy revealed the following, in part: Policy Statement: Staff shall make routine resident checks to help maintain resident safety and well-being. Policy Interpretations and Implementation 1. The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident's condition. Review of Resident #1's Nurse's Notes dated [DATE] revealed the following, in part: [DATE] at 8:00 p.m. Resident #1 was alert, awake, and oriented times 3. Signed by S16LPN. [DATE] at 8:18 a.m. Resident #1 requested to go to the ER for an evaluation related to weakness. [DATE] at 2:31 a.m. Resident #1 fell , hematoma noted to left side of forehead. Signed by S14LPN. [DATE] at 7:46 a.m. Resident #1 returned from hospital, awake but confused. Signed by S6LPN. [DATE] at 9:00 p.m. Resident has been lethargic/sleepy and unable to take pain medication. Oriented x2, confused. Signed by S14LPN. [DATE] at 11:49 a.m. Physical Therapy reported resident is more confused than the morning and also from the previous Friday when assessed. Signed by S5LPN. [DATE] at 8:00 p.m. Resident has been lethargic and sleepy and unable to take pain medication. Resident is oriented X2 and confused. Signed by S14LPN. Review of Resident #1's Physical Therapy notes dated [DATE] revealed the following: [DATE], Resident #1 refused to get out of bed due to feeling very weak. Nursing notified. Signed by S7PTA. [DATE], Resident #1 presented with continued confusion and nursing notified. Resident refused to get out of bed. Signed by S7PTA. Review of Resident #1's Nurse's Note dated [DATE] revealed at 5:00 a.m. Heard yelling and found Resident #1 on floor between bed and window. Assessed resident and noticed a golf ball sized knot to back of her head. Alert and oriented x 2 with intermittent confusion. Signed by S14LPN. Review of the emergency room records dated [DATE] revealed Resident #1 suffered from a large Acute on Chronic Subdural bleed. Resident #1 expired on [DATE] at 10:19 a.m. On [DATE] at 3:44 p.m., an interview was conducted with S6DOR. She stated S7PTA reported Resident #1's new increased confusion on [DATE] and [DATE] to S5LPN. She stated Resident #1's increased confusion was communicated in the daily meeting and the weekly meetings to S4LPN and S15PDON. She stated it was the responsibility of S4LPN and S15PDON to communicate to the Administrator. On [DATE] at 3:50 p.m. an interview was conducted with S3LPN/UM. She stated a meeting was held weekly with the interdisciplinary team. She stated any significant changes discussed in these weekly meetings would be brought to the DON/ADON and MDS nurses immediately. She stated changes in mental status or a new state of confusion would be considered a significant change. On [DATE] at 4:00 p.m. an interview was discussed with S1ADM. He stated S15PDON was responsible for notifying him of significant changes in a resident's condition. He stated he was never notified of Resident #1's change in mental status and should have. On [DATE] at 4:39 p.m. an interview was conducted with S2DON. She stated it was the nurse's responsibility to report changes in a resident's conditions to the physician and to the DON. The DON would then report changes in resident conditions to the administrator. On [DATE] at 4:35 p.m. an interview was conducted with S1ADM. He stated after the incident with Resident #1 on [DATE] S15PDON completed an in-service pertaining to fall prevention with staff. He stated no in-services were completed pertaining to notification of change in a resident's condition. On [DATE] at 4:47 p.m. an interview was conducted S4PADON. She confirmed working at the facility in [DATE]. She stated she notified S15PDON and S1ADM of Resident#1's falls on [DATE] and [DATE]. She stated falls were discussed in the daily morning meetings. She stated she was not aware of a significant change of Resident #1's mental status nor was she made aware of the change by the nursing staff. She stated Resident #1's normal mental status was alert and oriented x3 and weak, but not confused. She stated if Resident #1 returned from the emergency room confused, she would have considered it to be a significant change and the MD should have been notified. She stated if Physical Therapy would have communicated concerns of increased confusion to the nursing staff, she would expect them to contact the MD and to communicate these mental status changes to her and they did not. On [DATE] at 1:00 p.m., an interview was conducted with S1ADM. He stated the DON was responsible for supervising the nursing staff. He stated the DON was responsible and expected to report any changes in resident's status to him and the LPN should notify the physician. He confirmed the DON/ADON never communicated to him Resident #1 had increased confusion or a significant change and should have.

Based on interviews and record reviews, the facility failed to ensure each resident remained free from neglect for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for falls with major injury. The facility failed to ensure: 1. Nursing staff identified a change in condition for Resident #1 after a fall with head injury. 2. Nursing staff implemented appropriate interventions after Resident #1 began showing signs of a change in status after a fall with head injury; 3. Nursing Staff communicated the change in condition with Resident #1's physician. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a cognitively intact resident without confusion, on [DATE] at 7:46 a.m., when the resident returned from the emergency room after a fall and exhibited new onset signs of confusion. Nursing staff verbalized and documented Resident #1's increased confusion from [DATE] through [DATE] and failed to identify the change as a potential for head injury, implement new interventions, or notify the physician. On [DATE] at 5:00 a.m., Resident #1 fell and was transported to the emergency room where CT scan revealed a large Acute on Chronic Subdural bleed. Resident #1 expired on [DATE] at 10:19 a.m. S1ADM was notified of the Immediate Jeopardy situation on [DATE] at 7:30 p.m. The Immediate Jeopardy was removed on [DATE] at 5:12 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at a potential for more than minimal harm for the other 38 residents residing in the facility. Findings: Review of the facility's Change in Resident's Condition or Status policy revealed the following, in part: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation 1. The nurse will notify the resident's Attending Physician or physician on call when there has been (an): d. Significant change in the resident's physical/emotional/mental condition; i. Specific instruction to notify the Physician of changes in the resident condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) Review of the facility's Routine Resident Checks policy revealed the following, in part: Policy Statement: Staff shall make routine resident checks to help maintain resident safety and well-being. Policy Interpretations and Implementation 3. The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident's condition. Review of the facility's Falls- Clinical Protocol procedure revealed the following, in part: Assessment and Recognition Monitoring and Follow- Up 1.The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as a late fracture or subdural hematoma have been ruled out or resolved. a. Delayed complication such as while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. Review of the facility's Acute Condition Changes- Clinical Protocol procedure revealed the following, in part: 2.Direct Care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident and how to communicate these to the nurse. A review of the clinical records revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included, Other Lack of Coordination; Muscle Weakness; Age Related Physical Disability; Repeated Falls; Difficulty in Walking; Muscle Wasting and Atrophy; Myasthenia Gravis, Without Exacerbation; Myalgia; Unsteadiness on Feet; Abnormalities of Gait and Mobility; Tremor. A review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 15, which indicated Resident #1 was cognitively intact. Review of Resident #1's Nurse's Notes dated [DATE] revealed at 8:00 p.m. Resident #1 was alert, awake, and oriented times 3. Signed by S16LPN. Review of Resident #1's Nurse's Note dated [DATE] revealed at 2:31 a.m. Resident #1 fell , hematoma noted to left side of forehead. Signed by S14LPN. A review of the emergency room Report dated [DATE] revealed Resident #1 presented to the emergency room following a fall. The ER physician documented Resident #1 was alert and oriented to person, place, time and situation. Normal sensory, motor, speech and coordination was observed. Resident #1 was discharged back to the nursing facility with education concerning adult head injuries and when to get help. A review of the emergency room discharge education from [DATE] titled Head Injury, Adult revealed to get help right away if: you have a very bad headache, weakness in your arms/legs, more confusion or more grumpy moods, your symptoms get worse, you are sleepier than normal, you lose your balance or your speech is slurred. The education stated, Do not wait to see if symptoms go away. Get medical help right away. Review of Resident #1's Nurse's Notes dated [DATE] revealed the following, in part: [DATE] at 7:46 a.m. Resident #1 returned from hospital, awake but confused. Signed by S6LPN. [DATE] at 9:00 p.m. Resident has been lethargic/sleepy and unable to take pain medication. Oriented x2, confused. Signed by S14LPN. [DATE] at 11:49 a.m. Physical Therapy reported resident is more confused than the morning and also from the previous Friday when assessed. Signed by S5LPN. [DATE] at 8:00 p.m. Resident has been lethargic and sleepy and unable to take pain medication. Resident is oriented X2 and confused. Signed by S14LPN. A review of Resident #1's Neurological Assessments dated [DATE] revealed the following: [DATE] at 8:30 a.m., Resident #1's speech was unclear, unable to grasp hands and was disoriented but conversed. [DATE] at 9:30 a.m., Resident #1 continued to be disoriented and unable to grasp hands. Review of Resident #1's Physical Therapy notes dated [DATE] revealed the following: [DATE], Resident #1 refused to get out of bed due to feeling very weak. Nursing notified. Signed by S7PTA. [DATE], Resident #1 presented with continued confusion and nursing notified. Resident refused to get out of bed. Signed by S7PTA. Review of Resident #1's Nurse's Note dated [DATE] revealed at 5:00 a.m. Heard yelling and found Resident #1 on floor between bed and window. Assessed resident and noticed a golf ball sized knot to back of her head. Alert and oriented x 2 with intermittent confusion. Signed by S14LPN. A review of the emergency room Report dated [DATE] revealed Resident #1 presented to the emergency room at 6:09 a.m. following a fall at the nursing facility. A CT scan of the head was performed and revealed a large acute on chronic subdural hematoma causing a mass effect and a midline shift. Resident #1 was found without respirations at 7:31 a.m. and the time of death was pronounced at 10:19 a.m. A review of the Physician Communication Fax Sheets dated from [DATE] through [DATE] revealed no records of any communication faxed to Resident #1's physician regarding Resident #1's change in status. On [DATE] at 10:55 a.m., an interview was conducted with Resident #R6. Resident #R6 was observed to be awake, alert and oriented x4. She stated she was Resident #1's roommate. She stated she knew Resident #1 well, and she was completely coherent before she fell on [DATE]. She stated Resident #1 complained of head pain after her fall with head injury on [DATE]. She stated sometimes she would hold her head it hurt so badly. On [DATE] at 11:07 a.m., an interview was conducted with S12LPN. She stated upon admission to the facility, Resident #1 was cognitively intact and awake, alert, and oriented times 4 without signs of confusion She stated she did not care for the resident after the fall. On [DATE] at 11:36 a.m., an interview was conducted with S14LPN. She stated Resident #1 fell on [DATE], hit her head, and was sent to the ER. She stated prior to her fall she was alert and oriented x 3. She stated Resident #1 started to become confused after her return from the ER. She confirmed Resident #1 had a change in condition after a fall, but did not notify the MD because she worked night shifts. She stated the nursing staff were all aware of Resident #1's new onset confusion after the fall on [DATE]. She stated Resident #1 was very confused the morning of [DATE] prior to her next fall. She stated she was aware of the signs and symptoms of complications of a head injury and she should have notified the doctor and did not. On [DATE] at 4:35 p.m., an interview was conducted with S3LPN/UM. She stated for neurological changes, staff should notify the doctor. She stated Resident #1 was AAOx3 and had a BIMS of 15 upon admit in [DATE]. She stated when Resident #1 returned confused from hospital on [DATE], staff should have notified the doctor. On [DATE] at 8:59 a.m., an interview was conducted with S6LPN. She stated on [DATE] Resident #1 returned from the hospital confused and disoriented. She stated this was not Resident #1's normal mental status. She stated while taking care of Resident#1 she did realize she was exhibiting symptoms of a head injury, but should have notified the doctor and did not. On [DATE] at 9:25 a.m., an interview was conducted with S10MD. He stated he last assessed Resident #1 on [DATE] and her mental status was alert and oriented with no confusion. He stated nursing staff did not notify him of Resident #1's new onset of confusion after returning from theER on [DATE]. He stated the nurse should have notified him of Resident #1's change in mental status and he would have sent Resident #1 back to the ER for another evaluation. He stated he would have considered this a significant change which he should be notified for. He confirmed a CT result reading Acute on Chronic Subdural Hematoma meant there was some blood present which had worsened. He confirmed no notifications of Resident #1's change was conveyed to him at any time from [DATE] through [DATE] and should have. On [DATE] at 9:53 a.m., an interview was conducted with S7PTA. She stated on [DATE], after returning from the hospital, Resident #1 was confused. She stated Resident #1 complained of pain and nausea and refused to get out of bed. She stated she reported Resident #1's confusion and complaints to S5LPN. She stated this was not Resident's #1's normal mental status. She stated she again notified S5LPN on [DATE] regarding Resident #1's increased confusion. She stated Resident #1 participated in therapy prior to her fall on [DATE]. She stated after the fall on [DATE], she could no longer participate in therapy. On [DATE] at 11:45 a.m., an interview was conducted with S9PT. She stated Resident #1 was alert and oriented on admission to the facility. She stated when Resident #1 returned from theER on [DATE] she was confused which was not her normal mental status. She stated nursing staff was notified on [DATE] and [DATE]. She stated Resident #1 was able to participate in therapy and ambulate with assistance prior to her fall on [DATE]. On [DATE] at 1:25 p.m., an interview was conducted with S5LPN. She stated on a day-to-day basis Resident #1 was very alert and able to hold a conversation. She stated Physical Therapy made her aware Resident #1 was more confused on [DATE]. She stated she was aware of the signs and symptoms of a brain bleed following a head injury. She stated after her assessment of Resident #1 she used her nursing judgment and did not call the doctor. On [DATE] at 2:48 p.m., an interview was conducted with S13CNA. He stated on [DATE] he noticed Resident #1 had increased confusion which was not her baseline. He stated Resident #1's baseline was alert and oriented x3. He stated he reported it to S14LPN. He stated S14LPN noticed the confusion as well and did not call the doctor. He stated Resident #1 fell on the morning of [DATE] at 5:00 a.m. He stated Resident #1 stated she hit her head on the floor and was sent to the ER. On [DATE] at 4:47 p.m. an interview was conducted S4PADON. She stated she notified S15PDON and S1ADM of Resident#1's falls on [DATE] and [DATE]. She stated the falls were discussed in the daily morning meetings. She stated she was not aware of a significant change of Resident #1's mental status nor was she made aware of the change by the nursing staff. She stated Resident #1's normal mental status was awake, alert, oriented x3, and weak, but not confused. She stated if Resident #1 returned from the emergency room confused, she would have considered it to be a significant change and the MD should have been notified. She stated if Physical Therapy would have communicated concerns of increased confusion to the nursing staff, she would expect them to contact the MD and to communicate these mental status changes to her and they did not. On [DATE] at 2:31 p.m., an interview was conducted with S1ADM. He stated Resident #1 was admitted to the facility with a BIMS of 15. S1ADM stated he was not aware Resident #1 returned [DATE] with increased confusion and was also not aware Resident #1's physician was not notified of this change. He confirmed the physician should have been notified on [DATE] and again on [DATE] when Physical Therapy notified nursing of Resident #1's increased confusion. He stated he would expect staff to notify the doctor with any significant change in condition including increased confusion after a fall with head injury. 48184

Based on observations and interviews, the facility failed to store, prepare, distribute and serve all foods under sanitary conditions by failing to ensure dishes were properly sanitized prior to use. This deficient practice had the potential to affect 41 residents who were served meals from the facility's kitchen. Findings: Review of the facility's policy, titled Sanitization, revealed the following: POLICY: The food service area shall be maintained in a clean and sanitary manner. 9. Manual washing and sanitizing will employ a three-step process for washing, rinsing and sanitizing: a. Scrape food particles and wash using hot water and detergent, b. Rinse with hot water to remove soap residue, and c. Sanitize with chemical sanitizing solution. PROCEDURE: Using a Three-Compartment Sink Follow these steps to clean and sanitize items in a three-compartment sink. 1. Rinse, scrape, or soak the items before washing them. 2. Clean the items in the first sink. 3. Rinse the item in the second sink. -Dip them in water. 4. Sanitize the items in the third sink. -Soak them in a sanitizer solution as directed. -NEVER rinse items after sanitizing them. This could contaminate the surfaces. 5. Air-dry the items. On 04/06/2023 at 9:40 a.m., an observation was made of the three- compartment sink washing process with S8FSS. All three sinks were filled with water. The sinks were clearly labeled Wash, Rinse, and Sanitize. The Wash sink contained dirty dishes with noticeable bubbles. The middle sink, labeled Rinse, had visibly hot water with steam coming from it. S8FSS tested the third sink, labeled Sanitize, with the sanitizing concentration testing strip. The concentration testing strip did not register. At that time, an interview was conducted with S8FSS, and she stated the strip should have turned color, which would have indicated the sanitizer was 200units. S8FSS confirmed there was no sanitizing solution in the sanitizer sink. S8FSS stated the staff may have accidently put the sanitizer in the wrong sink to clean it. S8FSS then tested the middle sink, labeled Rinse, with the test strip. The test strip registered at 200units. At that time, the surveyor noted the sanitizer dispensing tube entering the rinse sink. S8FSS stated the correct method using a three-compartment sink was to Wash, Rinse and Sanitize. She stated she does not know why the sanitizer was being dispensed into the rinse sink. She stated the sanitizer should have been dispensed only in the sanitizer sink. On 04/06/2023 at 09:40 a.m. an interview was conducted with S9DC. She stated she was responsible for hand washing dishes. She stated she used the three-compartment sink process. She stated she was the only employee who washed the pots and pans yesterday and today. She stated her process was always to wash, rinse and sanitize. She stated she followed those three steps and followed the bins in order. She stated she had never moved the sanitizing dispensing tube.

Based on record reviews and interviews, the facility failed to ensure the residents remained as free of accident hazards as possible for each resident who was transported in the facility's van via wheelchair for 1 (#8) of 4 (#8, #18, #32, and #33) residents reviewed for transportation/accidents. The facility failed to secure Resident #8 safely during transport as recommended by manufacture guidelines. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's policy titled, Non-Emergency Facility Transpiration revealed the following: Policy Statement: Procedure for safe transport of facility residents in facility provided transportation for non-emergency purposes. Policy Interpretation and Implementation: Drivers will not transport residents in any chair that cannot be properly secured or maintain position for the purposes of safety securement. This includes: All electric and self-propelled chairs and scooters, any wheelchair identified by driver in disrepair or with malfunctioning breaking system, any chair that lacks secure anchor points to accommodate vehicle securement system. Only securement and safety devices specifically designed and approved for use in facility vehicles will be used in the transport of residents. Review of Q'Straint QRT-360 4-point Wheelchair Securement System Use and Care Manual revealed the following: Compliant Shoulder and Pelvic Belt Restraint must go across occupant's shoulder and pelvis (lap), and not be worn twisted or held away from the occupant's body by wheelchair components. We recommend using both a pelvic and shoulder belt together and not individually since it will compromise the performance of the system. J-Hooks must be attached to the WC19 compliant chair securement points or a solid wheelchair frame for all other wheelchairs (no spokes or movable components) at an approximate 45 degree angle with floor. Make sure shoulder belt does not rub against the occupant's neck. This system is a complete integrated system, do not alter or modify it in any way and do not interchange or substitute any components. Any deviation from these recommendations is the responsibility of the installer. Review of the Facility's Incident Log dated 12/02/2022 through 04/03/2023 revealed the following incident involving Resident #8.: Incident date: 03/23/2023 at 11:40 a.m. Incident type: Fall/no head injury Type of injury: Skin tear Location: Facility vehicle Equipment: wheelchair-motorized Narrative of incident and description of injuries: 11:40 a.m. van driver called and reported that resident slid out of his wheelchair in the van. 11:50 a.m. van driver pulled up to the side entrance. Resident noted sitting up in wheelchair in van. Resident states he slid out of the wheelchair. Denies pain. Small skin tear to left elbow noted. Resident states he does not want to go to the emergency room for evaluation. Immediate Actions taken: Assessed and provided wound care. Review of the MDS with an ARD of 02/16/2023 for Resident #8 revealed a BIMS of 14, which indicated he was cognitively intact. Further review revealed he was totally dependent on two staff members for transfers and mobility, was wheelchair bound, and he utilized a motorized wheelchair. On 04/03/2023 at 1:39 p.m., an interview was conducted with Resident #8. Resident #8 stated on 03/23/2023 after dialysis was completed, he was placed in the facility's transportation van in his motorized wheelchair. Resident #8 stated the van driver slammed on the brakes at a red light and he was thrown out of his wheelchair. Resident #8 stated his wheelchair was not locked and no lap or shoulder strap was in use. On 04/04/2023 at 1:01 p.m., an interview was conducted with S2DON. S2DON stated she was notified of the incident involving Resident #8. She stated she met the transport van at the entrance of the facility. She stated she observed Resident #8 seated in his wheelchair, in the van, in the locked position with a shoulder and lap seat belt, along with a blue soft lap belt, in place. She stated Resident #8 could not recall how he slipped out of the wheelchair. S2DON confirmed all passengers riding in the facility transport van should be restrained in the transport van with a lap and shoulder strap seat belt while the transport van is moving. On 04/05/2023 at 9:43 a.m., an interview was conducted with S4LPN. S4LPN stated she was assigned to Resident #8 the morning of the accident. S4LPN stated she received a telephone call from S6NT on 03/23/2023 around 11:30 a.m. reporting the incident. S4LPN stated she went to the transport van when it returned to the facility. S4LPN stated she spoke to Resident #8, and he reported the driver had come to a stop and he slid out from under a blue soft belt that was around waist. S4LPN stated when she arrived at the transport van, Resident #8 was sitting in his motorized wheelchair, wheelchair was locked, and a blue soft belt was in place. On 04/05/23 at 11:56 a.m., an interview was conducted with S7NT. S7NT stated on 03/23/2023, he received a call from S6NT requesting his assistance. S7NT stated he arrived on scene approximately 5 minutes later. S7NT stated the facility's transport van was pulled over to the side of the road. S7NT stated he found Resident #8 sitting on the floor of the transport van in front of his motorized wheelchair. S7NT stated Resident #8's wheelchair was locked in place. S7NT stated he could not recall if the wheelchair was strapped in or if the seat belt was in use. On 04/05/23 at 12:48 p.m., an interview was conducted with S6NT. S6NT stated he picked up Resident #8 up from the dialysis center on 03/23/2023. He stated Resident #8 was in his personal motorized wheelchair. S6NT stated he set Resident # up in the rear of the van. S6NT stated he secured the two back hooks to the right and left legs of the wheelchair and walked to the front and anchored the two front hooks. S6NT stated Resident #8 had a soft, blue belt with a white nylon strap around his stomach area, which secured him to the wheelchair. S6NT stated he did not use the manufacturer's shoulder and lap seat belt. S6NT stated, during transportation, he saw a red light and proceeded to stop. He stated he heard something behind him, and he turned and saw Resident #8 sitting on the van floor. On 04/06/23 at 09:47 a.m., a telephone interview was conducted with the Senior Account Manager for a local supply company. The Senior Account Manager stated he handled the supply account for the facility. The Senior Account Manager stated the blue soft belt-foam padded product was product #34170. The Senior Account Manager stated product #34170's intended use was for additional trunk support while in a wheelchair or geri-chair. The Senior Account Manager stated product #31470 was not designed to be used as a restraint or primary seat belt while in a moving vehicle. On 04/04/2023 at 1:01 p.m., an interview was conducted with S2DON. S2DON stated she was notified of the incident involving Resident #8. She stated she met the transport van at the entrance of the facility. She stated she observed Resident #8 seated in his wheelchair, in the van, in the locked position with a shoulder and lap seat belt, along with a blue soft lap belt, in place. She stated Resident #8 could not recall how he slipped out of the wheelchair. S2DON confirmed all passengers riding in the facility transport van should be restrained in the transport van with a lap and shoulder strap seat belt while the transport van is moving. The facility has implemented the following actions to correct the deficient practice: 1. Staff educated on appropriate wheelchair to use for transportation. Staff educated on ensuring the resident is properly secured in the van. Staff re-educated on securement devices. Education was provided by verbal, videos, and demonstration, return demonstration. Education was reinforced with practice demonstration, return demonstration. 2. The resident was evaluated by therapy and provided an appropriate wheelchair for transportation. 3. Message board in Electronic Medical Record was updated to notify nursing staff of resident's transportation status. 4. Security belt (soft belt) utilized during the transportation was taken out of use, and replaced with manufacture's seatbelt. 5. Monitoring to be performed to ensure compliance. 6. Describe how other residents that have the potential to be affected by the deficient practice will be identified; and what will be done for them. a. All residents that are transported by facility transportation have the potential to be affected b. Monitoring will be conducted for compliance. 7. The measure that will be put in place or the system changes that will be made to ensure that the deficient practice will not recur. a. Staff education provided on proper securement of residents during transportation, including training videos, verbal instruction, demonstration with return demonstration, continued follow up practice of demonstration and return demonstration. b. No motorized wheelchairs will be used for transportation. c. All residents will use appropriate wheelchairs for transportation d. All residents will use the new seatbelt with transportation e. Monitoring will be conducted for compliance. 8. Policy and procedure updated to reflect proper wheelchairs to be used for transportation, and chairs that are not to be used for transportation including motorized wheelchairs. Policy also updated reflect use of appropriate seatbelt and securement devices, and eliminating the use of the soft belt for transportation. Staff educated on policy. a. Monitoring will be conducted for compliance 9. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. Indicate how the corrective measures will be monitored. What quality assurance program will be put into place? Monitoring must include who how and how often and what will be does if problems are discovered. a. Education provided for proper seatbelt use and securement, education provided for proper wheelchairs to be used for transportation, education provided on policy b. Visual monitoring of securement of residents being transported. Monitoring will be conducted by Administrative staff/designee c. Monitoring will be conducted twice a week for 4 weeks, then weekly ongoing to ensure sustained compliance, starting 3/23/23 d. All monitoring will be evaluated by QAPI team at regularly scheduled meetings e. Any issues identified will be addressed immediately by administrative staff, and any re-education or modified monitoring will be put into place f. Any policy and procedures will be updated as needed 10. Include dates when corrective action will completed. a. Corrective action was completed on 3/23/23

Based on observations and interviews, the facility failed to ensure foods were prepared, distributed, and served under sanitary conditions by not ensuring staff correctly sanitized the food thermometer before using it to take the food temperatures. Based on the Resident Census and Condition of Residents report the facility had a total census of 32 residents. There were 30 out of 32 residents that were served food from the kitchen. Findings: An observation made on 04/18/2022 at 10:50 a.m. of S10DM who took a food thermometer probe from a glass of ice water and placed it into a pan of white beans. After taking the temperature of the pan of white beans, she placed the food thermometer back into the glass of ice water. Without sanitizing the food thermometer probe, she placed it in a pan of fried okra. S10DM then placed the thermometer back into the now cloudy glass of ice water. S10DM repeated the same procedure until she completed taking the temperatures for all the foods on the steam table. S10DM was observed not properly washing, rinsing, and sanitizing the food thermometer after using the thermometer. On 04/18/2022 at 10:52 a.m., an interview was conducted with S10DM. She verified she failed to properly wash, rinse, and sanitize the food thermometer prior to and during taking the food temperatures on the serving line. On 04/20/2022 at 12:30 p.m., an interview was conducted with S1ADM. She verified the facility's policy was to clean and sanitize thermometers between each temperature check when checking food temperatures. She verified that the staff did not follow correct procedure.

Based on record review, observation, and interviews, the facility failed to maintain an infection prevention and control program designed to prevent or contain the spread of COVID-19. The facility failed to ensure staff utilized Personal Protective Equipment while in a room for 1 (#19) of 1 residents on contact isolation precautions for COVID-19 and while mail was being delivered. There were 32 residents residing in the facility per facility census report. Findings: A review of the facility Policy and Procedure for Infection Prevention and Control revealed the following: Isolation- Categories of Transmission-Based Precautions Policy Statement 1. Standard Precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status. Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. Resident #19 A review of Resident #19's record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/19/2022, Resident #19 was observed to be on isolation precautions for COVID-19. An observation was made on 04/19/2022 at 08:57 a.m. of Resident #19's door with an isolation notification sign and an isolation station hanging on the outside of the door. S7AD was in the hall to deliver mail to residents and she entered Resident #19's room without donning or doffing required PPE for isolation precautions. She had multiple envelopes observed in her hands. She did not perform hand hygiene when entering or exiting Resident #19's room. On 04/19/2022 at 08:58 a.m., an interview was conducted with S7AD. She verified she had entered Resident #19's room without donning or doffing PPE and she had not performed hand hygiene when entering or exiting the room. She said Resident #19 was on isolation for COVID-19 and she should have donned and doffed a gown and gloves before entering Resident #19's room. An observation was made on 04/19/2022 at 08:59 a.m. of S7AD push Resident #2 in a wheelchair to the common room where the television was located. She had still not performed hand hygiene and she was still holding the mail. She then went into and out of four additional rooms, on the same hall as Resident #19 resided on, without performing hand hygiene and while she passed out the mail. On 04/19/2022 at 03:41 p.m., an interview was conducted with S1ADM. She said S7AD should not have entered Resident #19's without PPE as the isolation notice was on the door and he was on isolation for COVID-19. She said their policy for infection control indicated staff should don and doff PPE before entering and exiting a resident's room who was on isolation for any reason. She said staff should perform hand hygiene when entering and exiting every resident's room. S1ADM verified S7AD was not following the process when she did not don and doff PPE while in Resident #19's room or perform hand hygiene between residents and resident rooms.

Based on record reviews and interviews, the facility failed to ensure each resident had the right to be free from physical abuse by another resident for 1 (#32) of 1 (#32) resident reviewed for resident-to-resident altercations. The facility failed to protect Resident #32 from being hit by Resident #1. Findings: A review of facility's Abuse Prevention Program revealed, in part: Our residents have the right to be free from abuse. As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff and other residents. Definitions revealed abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also included the deprivation by an individual, including a caretaker, of good or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled though the use of technology. Resident #1 Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses, which included Major depressive disorder, recurrent and Sequelae of unspecified [CONDITION(S)] disease. Review of the Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/02/2022 revealed Resident #1 had a BIMS (Brief Interview of Mental Status) score of 15, which indicated he was cognitively intact. Resident #32 Review of the clinical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS with an ARD of 04/07/2022 revealed Resident #32 had a BIMS score of 15, which indicated he was cognitively intact. Review of the facility's Resident Incident Report revealed the following: Incident Type- Abuse resident-resident Date/Time - 02/22/2022 at 03:00 p.m. Type of Injury- no injury Location- Hallway on Unit Incident Reported by- S3LPN Narrative of incident and description of injuries: Resident #32 was struck by another resident and also pulled by his shirt until he tipped over in his wheel chair. Both residents were separated and evaluated. Physician and both resident's family members were notified. Review of the facility's Resident Incident Report revealed the following: Incident Type- Abuse resident-resident Date/Time - 02/22/2022 at 03:00 p.m. Type of Injury- no injury Location- Hallway on Unit Incident Reported by- S3LPN Narrative of incident and description of injuries: Resident #1 was physically aggressive to another Resident #32. Both resident were separated and evaluated. Physician and both resident's family members were notified. Review of the facility's Nursing Notes revealed an entry by S4LPN on 02/22/2022 at 03:00 p.m. regarding resident to resident altercation involving Resident #1 and Resident #32. S4LPN called to north back hall per staff member, Resident #1 sitting in wheelchair near Resident #32 who was tipped over in his wheelchair. S8HK reported Resident #1 hit and pulled Resident #32 over causing him to fall out of his wheelchair. When asked what happened, Resident #1 stated Resident #32 told him he needed to stop urinating on the toilet seat. He stated it made me mad so I punched the Resident #32 in the face and pulled him over in the wheelchair. Resident #1 was still hollering and cursing at the Resident #32. On 04/18/2022 at 03:18 p.m., an interview was conducted with Resident #1. He stated he recalled the incident dated 02/22/2022. He stated Resident #32 was messing with him. He stated he warned Resident #32 to stop. He stated he had had enough and slapped Resident #32 in the head and then pulled him by his shirt causing his wheelchair to tip over. On 04/19/2022 at 10:09 a.m., an interview was conducted with S4LPN. She said she responded to the incident on 02/22/2022. She stated she arrived to the scene to find Resident #32 seated in his wheelchair tipped over. She stated Resident # 1 stated he slapped Resident #32 and pulled his wheelchair over. On 04/19/2022 at 12:40 p.m., an interview was conducted with S8HK. She stated on 02/22/2022 at 03:00 p.m. she witnessed Resident #1 and Resident #32 arguing loudly in the hallway. She stated Resident #1 leaned over and slapped Resident #32 on the top of his head. She stated she ran over to separate the two residents when Resident #1 grabbed Resident #32 by the shirt and pulled him until his wheelchair tipped over. On 04/19/2022 at 03:02 p.m., an interview was conducted with Resident #32 he stated he recalled the incident dated 02/22/2022. He stated Resident #1 was urinating on the floor and toilet and putting feces on the floor and toilet in the shared restroom. He stated was sitting in the hall near the door way of his room when Resident #1 entered the hall. He stated he ask Resident #1 to stopped messing up the restroom. He stated Resident # 1 wheeled up to him slapped him on the head, grabbed his shirt, and tilted his wheelchair over to the floor. On 04/20/2022 at 09:35 a.m., an interview was conducted with S2DON. She verified Resident #32 was not protected from abuse by placing Resident # 1 in the adjoining room requiring them to share the restroom.

Based on record reviews, observation, and interviews, the facility failed to ensure licensed nursing staff had the knowledge, competencies, and skill sets to provide nursing services to ensure residents attained and/or maintained the highest practicable physical, mental, and psychosocial well-being. The nursing staff failed to ensure: A.) A physician's orders [REDACTED].#39) of 9 (#25, #30, #39, #55, #56, #207, #208, #210, #211) residents reviewed who were transferred out of the facility in January 2020; and B.) A PEG tube feeding was administered per the physician's orders [REDACTED].#41) of 2 (#41, #356) residents reviewed who received intermittent tube feedings. Findings: A.) Resident #39 A review of Resident #39's clinical record revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A review of the Quarterly MDS with an ARD of 01/27/2020 revealed Resident #39 had a BIMS of 12 indicating she had moderately impaired cognition. She had the ability to understand others and make herself understood with clear speech. She was a two person assist for transfers. A review of the physician's orders [REDACTED].M. revealed an order to consult ENT per Primary Physician. A review of the Discharge Summary from Hospital dated 01/21/2020 revealed an order to follow up with specialist within 10-12 days. Comment: ENT physician for dizziness. A review of the Patient Care Requisition from Hospital dated 01/21/2020 revealed Order: Discharge Patient. Special instruction: Needs ENT follow up appointment. On 03/04/2020 at 01:05 P.M., an interview was conducted with S2LPN. She said Resident #39 did not follow up with ENT per physician's orders [REDACTED]. On 03/04/2020 at 03:06 P.M., an interview was conducted with S1DON. She said the consult written by Resident #39's physician had slipped through the crack. She said the ENT appointment for Resident #39 was not made per her physician's orders [REDACTED]. B.) Resident #41 A review of Resident #41's clinical record revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A review of the Significant Change MDS with an ARD of 01/28/2020, revealed Resident #41 had a BIMS of 00 indicating he had severely impaired cognition. He was indicated to sometimes understand others and he had no speech. He was a two person assist for transfers. A review of the physician's orders [REDACTED].M. to 6:00 A.M. A review of the MAR indicated [REDACTED].M. to 6:00 A.M. A review of the Dietician Consult note dated 02/29/2020 revealed, in part: tube feeding order: Glucerna 1.5 at 60 cc per hour X12, with weight decline recommend to increase feeding to 65 cc per hour Glucerna 1.5. A review of the Dietician Consult note dated 01/17/2020 revealed, in part: recommend to begin Glucerna 1.5 at 15 cc per hour increasing until maximum of 60 cc per hour is provided over 12 hours. On 03/05/2020 at 08:40 A.M., an observation was made of Resident #41 asleep in his bed with tube feeding infusing at 65cc/hour via feeding pump. On 03/05/2020 at 08:45 A.M., an interview was conducted with S2LPN. She said Resident #41's tube feeding was supposed to infuse from 6:00 P.M.-6:00 A.M. daily. She said she did not go into Resident #41's room this morning so she did not see the tube feeding was still infusing. S2LPN verified Resident #41's tube feeding should not be infusing at 08:45 A.M.

Based on observations, interviews, and record reviews, the facility failed to ensure services were provided to meet the professional standards of quality for 2 (Resident #2, #8) of 8 (Resident #1, #2, #3, #4, #5, #6, #7, #8) diabetic residents reviewed for drug monitoring. The facility failed to: 1. identify specific approaches in the resident's care plans related to signs and symptoms of hypo/[MEDICAL CONDITION] (#2, #8); 2. notify the resident's physician, or legal representative of the resident's confusion, hallucination and slurred speech (#2); 3. ensure accuchecks (blood glucose monitoring) was done on 2 (#2, #8) diabetic residents that were receiving [MEDICATION NAME], a medication the help control blood sugar levels; and 4. notify EMS(Emergency Medical Service) that Resident #2 had a low blood glucose level of 26 that had just been taken before EMS arrived at the facility. Resident #2 was placed in an Immediate Jeopardy situation on [DATE] when he was found to be confused, and hallucinating. On [DATE] at 9:30 a.m. he was not easily redirected and had slurred speech. At 8:00 p.m., the same evening, he was assessed by his nurse to be in bed with his eyes closed, lethargic and could not be aroused. At 8:45 p.m. he was found with apnea episodes and completely unresponsive with a blood glucose level of 26. At 9:20 p.m. Resident #2 was transferred to a local hospital. The Administrator was notified of the Immediate Jeopardy situation on [DATE] at 1:55 p.m. A plan of removal was presented by the Administrator which read as follows: 1. Resident #2 expired in hospital in March, 2016. 2. Any diabetic resident taking oral hypoglycemic agents who is not on routine blood sugar monitoring has the potential to be affected by alleged deficient practice. A. Facility will immediately identify all current residents taking oral hypoglycemic who do not have routine Accucheck orders and notify MD (Medical Doctor) for further orders. 3. To ensure deficient practice does not recur, the facility will: 1. All residents who are admitted or readmitted to the facility with a [DIAGNOSES REDACTED]. 4. To ensure solutions are sustained the facility will: 1. Inservice all Nurses and CNA's (Certified Nursing Assistants) on signs and symptoms of hypo/[MEDICAL CONDITION] beginning [DATE]. 2. Inservice all nurses regarding notification of physician if resident is admitted /readmitted with [DIAGNOSES REDACTED]. 3. Inservice all nurses regarding potential adverse effects of hypoglycemic medications beginning [DATE]. *All inservices for CNA's and nurses begun immediately on [DATE]. All inservices for scheduled full time employees will be completed by [DATE]. Part time and PRN (as needed) employees will be inserviced prior to their next scheduled shift. Inservice for CNA's and nurses will be added to new employee orientation packet immediately beginning [DATE] to ensure education is provided before working with the residents. 4. Nurse Manager will audit all admit and readmit charts for [DIAGNOSES REDACTED]. 5. Compliance with current residents will be achieved on [DATE]. The Immediate Jeopardy was removed on [DATE] at 4:55 p.m. when the surveyor confirmed all residents' records were reviewed for blood glucose monitoring. The deficient practice remains at a level 3, potential for harm for Resident #8. Findings: Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses (As amended through December, 2009) Subpart, I. Practical Nurse, under subchapter E.Curriculum Requirements revealed in part .3. development of those qualities and personal characteristics needed to practice practical nursing safely, effectively and with [MEDICATION NAME], including increased and ongoing development of self awareness, sound judgment, prudence, ethical thing and behaviors, problem solving and critical thinking abilities .7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, obstetrical nursing, pediatric nursing, and mental health. Clinical experience shall include, but not be limited to, the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, IV therapy, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety and infection control, communication and documentation, and writing as member of the interdisciplinary health care team . A review of the drug package insert for [MEDICATION NAME] revealed the following: Precautions [DIAGNOSES REDACTED]: All sulfonylurea drugs are capable of producing severe [DIAGNOSES REDACTED]. Proper patient selection, dosage, and instructions are important to avoid hypoglycemic episodes. Information for Patients: Patients should be informed of the potential risks and advantages of [MEDICATION NAME] and of alternative modes of therapy. They should also be informed about the importance of adherence to dietary instructions, of a regular exercise program, and of regular testing of blood glucose. Laboratory Tests: Fasting blood glucose should be monitored periodically to determine therapeutic response. A review of the facility's Policy and Procedure entitled Care of the Diabetic Resident revealed the following: Policy: It is the policy of ________ to ensure that all residents diagnosed with [REDACTED]. Every effort will be made to prevent residents from hyperglycemic or hypoglycemic episodes. Procedure: 1. Assess level of blood sugar by glucometer check. This may be done once a day or up to four (4) times daily and may also be done on an as needed basis, depending on the physician's orders [REDACTED]. 3. If the blood sugar is below sixty (60) or greater than 400 then notify the physician unless otherwise stated in doctor's orders. 11. All residents on diabetic monitoring must have a Diabetic Monitoring Flowsheet in their medical record. This must be filled in accurately and appropriately. 12. The Director of Nursing or her designee will monitor routinely to make certain that residents are being monitored on a regular basis. She will report findings to the Quality Assurance Committee. Resident #2 A review of the medical records from the local hospital revealed the following: admitted : [DATE] discharge date : [DATE] Discharge Summary stated the following: Final Diagnoses: [REDACTED]. Hx (History) of [MEDICAL CONDITION] and behavioral disturbances. 2. Hx of [MEDICAL CONDITION]. 3. [MEDICAL CONDITION]. History of Present Illness: This patient is a [AGE] year old male transferred from __________a local hospital for altered mental status. He lives in nursing home became angry, was then behavioral disturbances. He was admitted to the hospital. He was ruled out for any metabolic issues. The patient is medically stable to be discharged to inpatient psychiatric facility. A review of the medical records from the inpatient psychiatric facility revealed the following: Admit: [DATE] Discharge: [DATE] back to nursing home Resident was receiving [MEDICATION NAME] 2 mg by mouth twice a day in inpatient psychiatric facility as well as accuchecks four times a day. A review of the facility's clinical record revealed the following: Resident #2 was a [AGE] year old male and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A review of the physician orders [REDACTED]. Diagnoses: [REDACTED].>Glimepiride ([MEDICATION NAME]) 2 mg 1 tab PO (by mouth) twice daily for diabetes - 8:00 a.m., 4:00 p.m. Review of the care plan revealed no specific approaches documented to monitor the signs and symptoms of hypo/[MEDICAL CONDITION]. A review of the social worker note revealed the following: [DATE] at 3:20 p.m. - He has had a decline in his mental status. He displayed an hallucination. He asked SSD (social service director) to more the snake on his bed. SSD reassured him that there was not a snake on his bed. SSD also informed his nurse on today of the hallucination. A review of the nurse's notes revealed the following: [DATE] at 7:20 p.m. - Resident arrived at facility from __________Behavioral Health Center in Houma, LA with Dx (Diagnosis) of CAD ([MEDICAL CONDITION]),[MEDICAL CONDITION](Hypertension), DM (Diabetes), and Cardiac Arrythmia. Resident was awake and oriented. Skin W/D (Warm/Dry) to touch. Respiration even and nonlabored. Propels himself in w/c (wheelchair) has good mobility .Transfers independently uses w/c for ambulation. [DATE] at 8:00 p.m. - Up in wheelchair in hallway, no s/s (signs/symptoms) of distress noted, increase confusion noted. (Signed by S4LPN) [DATE] at 9:30 a.m. - Sitting up to w/c (wheelchair) alert, engages in conversation confused, disoriented. Not easily redirected. Speech slurred and difficult to understand at times. (Signed by S3LPN) [DATE] at 8:00 p.m. - Resident lying in bed with eyes closed not easily aroused, very lethargic, attempted to arouse resident for med administration without success, came back at 8:45 p.m. for a second attempt to give meds, resident found to be having apneic episodes and completely unresponsive, all attempts to arouse failed. V/S (Vital Signs) ,[DATE], 83, 96.5, respirations uneven and labored, CBG (Capillary Blood Glucose) -26, R/P (Responsible Party) alerted to current situation and agreed to send out to ER (emergency room ) at _______the local hospital at 9:05 p.m., called EMS (Emergency Medical Service) at 9:10, notified _____the local hospital at 9:12 p.m., EMS (Emergency Medical Service) arrived for transport of resident to the local hospital at 9:20 p.m. (Signed by S4LPN) There was no documentation the physician was notified on any of the occasions where staff reported and where there was documentation that the resident was confused, had hallucinations or had slurred speech. A review of the local EMS (Emergency Medical Service) company records revealed the following: [DATE] Call received: 2111 (9:11 p.m.) Respond: 2112 (9:12 p.m.) On Scene: 2114 (9:14 p.m.) A review of medical records from ___________ a local hospital revealed the following: Registered: [DATE] at 9:34 p.m. discharged : [DATE] at 1:24 a.m. ED (Emergency Department) Physician note on [DATE] at 9:54 p.m. revealed the following: Associated Diagnoses: [REDACTED].>History source: EMS Arrival mode: Ambulance History limitation: unresponsive History of Present Illness: The patient presents with [DIAGNOSES REDACTED]. The onset was just prior to arrival. The blood sugar was 26 mg (Milligrams) /dL (Deciliter). Risk factors consist of diabetes mellitus, hypertension and [MEDICAL CONDITION]. Prior episodes: none. Therapy today: intravenous [MEDICATION NAME]. Patient sent from NH (nursing home) with unresponsive, as per NH (nursing home) staff patient did not eat all days and he was sleeping most of the days, this evening staff was unable to wake up patient. Review of System: Patient is unresponsive. Vital Signs: [DATE] at 2138 Temperature Axillary: 36.5 Degree Celsius, Peripheral Pulse Rate: 78 bpm (beats per minute), BP ,[DATE], SpO2 99%, Oxygen Flow Rate: 15 L/min, Oxygen Therapy: Nonrebreather mask Blood Glucose, Capillary, POC (Point of Care) - [DATE] at 10:45 p.m. 54 mg/dL Low [DATE] CT of head - no acute findings. Impression and Plan: Diagnosis: [REDACTED]. Calls - Consult - [DATE] at 12:38 a.m., case discussed with another physician - accepted patient for transfer at ____________another local hospital. Plan - Family, lab results discussed with Patient's family at bedside. Family is requesting to go to a different facility because he has been at the local hospital twice recently. [DATE] at 10:32 p.m. Chest X-Ray revealed the following: Clinical Information: [DIAGNOSES REDACTED]. Patient unresponsive. Impression: There is no acute cardiopulmonary disease. Blood Chemistry lab [DATE] at 9:50 p.m. glucose 90 A review of the medical records from ____________ a local hospital #2 revealed the following: Discharge Summary: admitted : [DATE] discharged : [DATE] Final Diagnoses: [REDACTED]. Severe metabolic [MEDICAL CONDITION]. 2. [DIAGNOSES REDACTED] 3. Acute [MEDICAL CONDITION]. 4. [MEDICAL CONDITION]. 5. History of pacemaker. 6. Hypertension 7. Diabetes 8. Chronic [MEDICAL CONDITION] 9. History of [MEDICAL CONDITION] 10. [MEDICAL CONDITION] 11. [MEDICAL CONDITION] 12. [MEDICAL CONDITION] History of Present Illness: The patient was a [AGE] year old resident of ________Nursing Home, transferred to __________ a local hospital for evaluation of [DIAGNOSES REDACTED]. The patient ended up at this hospital with altered mental status, [MEDICAL CONDITION], and [MEDICAL CONDITION].[MEDICAL CONDITION] was ruled out. He was a DNR, on comfort measures only per family. He was pronounced on [DATE] at 4:55 p.m. On [DATE] at 10:53 a.m. an interview was conducted with S5SSD. After reviewing her progress note dated [DATE] at 3:20 p.m. she stated the resident asked her to remove the snake on the bed. She stated she told the S2LPN on [DATE] around 3:15 p.m. She stated she clearly remembered the incident because S2LPN was on med pass and her cart was right in front of her office when she told her about his hallucination. She stated S2LPN informed her that he asked her to move the man in his room. She was asked if Resident #2 ever had slurred speech. She stated he had very clear speech and it wasn't until that time when he started to decline. On [DATE] at 11:27 a.m. an interview was conducted with S2LPN. She stated the CNAs would report any change in appetite to the nurse. She was asked if she ever checked his blood glucose. She stated he would ask her periodically to check his sugars. She stated, I think he was curious. She stated she would write the accucheck on the back of the MAR (Medication Administration Record). She was asked if she documented any sugar checks on the back of the MAR. After reviewing the clinical record, she stated, I don't see it, No. She stated she used the diabetic flow sheet if the resident was on scheduled accuchecks. She stated she didn't see one of those in the record. She stated it was usually like 120s and didn't require any coverage. She stated, the resident usually asked her before supper to check his sugar. She stated he was admitted with [MEDICATION NAME]. She stated she didn't remember Resident #2 ever having hallucinations. After she reviewed the nursing care plans she was asked if there were any specific interventions to monitor for signs and symptoms of hypo/[MEDICAL CONDITION]. She stated, No. On [DATE] at 12:04 p.m. an interview was conducted with S3LPN. She stated she was the nursing station manager. She was asked how did the staff know when to perform an accucheck on a diabetic resident. She stated, We go by the physician orders, if there are no orders for accu checks then we don't check it unless we see a need to check it. She stated if we did not have an order and resident was on [MEDICATION NAME] we did not check the sugar unless the resident was lethargic, sweating, clammy, cool to touch, or had confusion. She stated if accuchecks were not ordered then it won't be documented unless it was a problem and we needed to contact the physician. She was asked what was the facility's protocol for taking accuchecks on diabetic residents. She stated there was no protocol for accuchecks, we just follow the physician orders. She stated every now and then he would want the staff to check his sugars. She was asked if anyone contacted the physician to see if he wanted accuchecks done on the resident. She stated, If he wasn't on accuchecks then we don't ask for them to be placed on accuchecks. She confirmed the nursing notes did not consistently document confusion, disorientation and slurred speech as his usual state. On [DATE] at 1:16 p.m. an interview was conducted with S4LPN. She stated when he came back he changed. She stated he would skip meals and it was reported during shift change. She explained the skipped meals wasn't charted usually just reported during shift change. She stated the nurse would receive the information from CNAs. She stated he usually missed his dinner meal. She stated she did remember him refusing snacks. She was asked when did she perform accuchecks on diabetic residents. She stated it depends on the physician orders [REDACTED]. She stated if there was no order she would call the physician to clarify. She stated he was not getting accu checks. She was asked to explain the events that occurred on [DATE]. She stated on [DATE] at 6:00 p.m. he was in room in bed and snoring. She said, He was doing the same thing as the day before, he was out of it, lethargic. She stated she was told in report that he ate his breakfast, half his lunch and skipped dinner. She stated, she clearly remembers that he did skip dinner that night. She stated she was starting med pass at 6:30 p.m. and got to him around 7:00 p.m., she stated he was not easily aroused, she shook him, and he moaned. She stated before she went to the back hall to complete her med pass at about 8:20 or 8:30 p.m. she went back to him and he was more lethargic and noticed he wasn't breathing right. She stated he had Kussmaul breathing, and she took his vital signs. She stated his vital signs were stable then she checked his glucose and it was 26. She was asked if she notified the physician the first time she found the resident lethargic. She stated, No, because I didn ' t know of the nurse before me had already informed the physician. She was asked if she notified the physician of the second time when the resident was found to be having apneic episodes and completely unresponsive. She stated, No, we usually send a fax sheet to the MD. She stated she notified the resident's daughter. On [DATE] at 1:39 p.m. a telephone interview was conducted with the EMT (emergency medical technician). He stated he did recall transporting Resident #2 from the facility to a local hospital. He was asked to describe the situation when he arrived to the facility. He stated when he arrived on the scene he found the resident lying in bed snoring with respirations of 6. He stated when he arrived at the facility he was told the patient was sleeping all day, and staff assumed patient was tired all day. When he was en route to hospital he found out through the paperwork the patient was a DNR. He stated the patient had a recent surgical wound to his chest area but the nursing staff did not tell him what type of surgery he had. He stated he took CBG (capillary blood glucose) in route and it was 20. He stated the nursing staff never informed him that the patient's glucose was 26. He explained that he would have started the D50 (Intravenous [MEDICATION NAME] 50%) sooner. He stated the nurse told him she did not take a blood sugar because there was no orders to do it. On [DATE] at 2:32 p.m. an interview was conducted with S1DON. She stated if accuchecks were on the routine physician orders [REDACTED]. She stated she and the assistant director of nursing would make sure the resident's accuchecks were being done and they were going by the physician orders. After reviewing the nurses' notes she confirmed there was no documentation by the nursing staff of the resident's hallucination or that the physician or responsible party was notified. She also confirmed there was no nursing note notifying the physician or responsible party of the resident's confusion, disorientation or slurred speech on [DATE] at 9:30 a.m. She explained, If someone never had hallucinations and suddenly has hallucinations then there would be issue. She confirmed there was no nursing note of the resident's status from [DATE] at 9:20 a.m. until 8 p.m. when he was found in his bed lethargic and could not be aroused. On [DATE] at 8:58 a.m. a telephone interview was conducted with S10MD. He stated he was the primary physician for Resident #2. He confirmed Resident #2 was a diabetic and was taking [MEDICATION NAME] 2mg PO (by mouth) twice a day. He was asked how often should the nursing staff have been checking his blood glucose level. He stated, Four times a day, AC (before meals) and HS (at bedtime). He stated if a diabetic resident on medication did not have an order for [REDACTED]. He stated, No, he was very articulate. He was asked if Resident #2 ever had hallucinations. He stated, No. Surveyor read out load to S10MD the social worker note dated [DATE] at 3:20 p.m. wherein the resident told the social worker to get the snake out of his bed and the social worker informed the nurse about the hallucination. He was asked if he should have been notified of the hallucination. He stated, Yes. Surveyor read out loud to S10MD the nursing note dated [DATE] at 8:00 p.m. He was asked if the resident had an increase in confusion should he have been notified. He stated, Yes. Surveyor read out loud to S10MD the nursing note dated [DATE] at 9:30 a.m. Sitting up in wheelchair, alert, engages in conversation. Confused/disoriented. Not easily redirected. Speech slurred and difficult to understand at times. He was asked if he would expect the nursing staff to perform an accucheck on the resident. He stated, Yes. He was asked if he would expect the staff to notify him of the resident's condition on [DATE] at 9:30 a.m. He stated, Yes. He was asked if he was notified on [DATE] at 8:00 p.m. when the resident was found in bed with eyes closed, not easily aroused, and very lethargic. He stated, No. Resident #8 Review of the clinical record revealed Resident #8 was an [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. [MEDICATION NAME] 4 mg (milligrams) p.o. (by mouth) daily for Diabetes (start date: [DATE]) [MEDICATION NAME] 100 mg p.o. daily for Diabetes (start date: [DATE]) Basic Metabolic Panel - January, May, September HgbA1C Q (every) 3 months - January, May, September Review of the MAR (medication administration record) for March, April, and [DATE] revealed the resident received [MEDICATION NAME] 4 mg and [MEDICATION NAME] 100 mg p.o. daily. There was no documentation of routine accuchecks performed on the resident. Review of lab tests performed on [DATE] revealed the following results: HgbA1C - 7.9 (High). Reference range 4XXX,[DATE].5 Glucose Level - 136 (High). Reference range ,[DATE] On [DATE] at 11:11 a.m., an observation of Resident #8 was performed. He was observed lying in his bed. He was awake, alert, and oriented. On [DATE] at 11:12 a.m., an interview was conducted with Resident #8. He stated he became a resident at the facility in August of 2015. Resident #8 further stated he was a diabetic and has taken diabetic medications for at least [AGE] years. Resident #8 verified he was taking daily medicines by mouth for diabetes. He was asked if he checked his blood sugars at home before entering the facility. He stated, Yes. Resident #8 was asked if the facility's staff checked his blood sugars routinely. He stated, No. On [DATE] at 11:22 a.m., an interview was conducted with S8LPN. S8LPN verified Resident #8 was a diabetic. She further verified Resident #8 takes [MEDICATION NAME] and [MEDICATION NAME] daily. S8LPN was asked if routine accuchecks were performed on Resident #8. She stated no routine accuchecks were performed on the resident. On [DATE] at 11:47 a.m., a telephone interview was conducted with S9MD. He verified he was Resident #8's primary physician. He further verified the resident was a diabetic. After reviewing the resident's medications with him and the lab results of an increased HgbA1C and increased blood glucose level on [DATE], S9MD was asked if any routine accuchecks should have been conducted on Resident #8. S9MD stated he would have expected Resident #8 to receive accuchecks daily, or at the very least, weekly to monitor his blood glucose levels, especially with a HgbA1C level of ,[DATE].

Based on observations, interviews and record reviews, the facility failed to ensure that a resident on an diabetic drug received adequate monitoring and was assessed for adverse consequences which indicated the dose should be reduced or discontinued for 2 (Resident #2, #8) of 8 (Resident #1, #2, #3, #4, #5, #6, #7, #8) residents reviewed for unnecessary medications. The facility failed to: 1. Identify specific approaches in the resident's care plans related to signs and symptoms of hypo/[MEDICAL CONDITION] (low and high blood glucose levels) (#2): 2. Notify the resident's physician, or legal representative of Resident #2's confusion, hallucination and slurred speech. 3. Ensure Accuchecks (blood glucose monitoring) was done on diabetic residents (#2, #8) that were receiving diabetic medication [MEDICATION NAME], a medication to help control blood sugar levels. Resident #2 was placed in an Immediate Jeopardy situation on [DATE] when he was found to be confused, and hallucinating. On [DATE] at 9:30 a.m. he was not easily redirected and had slurred speech. At 8:00 p.m., the same evening, he was assessed by his nurse to be in bed with his eyes closed, lethargic and could not be aroused. At 8:45 p.m. he was found with apnea episodes and completely unresponsive with a blood glucose level of 26. At 9:20 p.m. Resident #2 was transferred to a local hospital. The Administrator was notified of the Immediate Jeopardy situation on [DATE] at 1:55 p.m. A plan of removal was presented by the Administrator which read as follows: 1. Resident #2 expired in hospital in March, 2016. 2. Any diabetic resident taking oral hypoglycemic agents who is not on routine blood sugar monitoring has the potential to be affected by alleged deficient practice. A. Facility will immediately identify all current residents taking oral hypoglycemic who do not have routine Accucheck orders and notify MD (Medical Doctor) for further orders. 3. To ensure deficient practice does not recur, the facility will: 1. All residents who are admitted or readmitted to the facility with a [DIAGNOSES REDACTED]. 4. To ensure solutions are sustained the facility will: 1. Inservice all Nurses and CNA's (Certified Nursing Assistants) on signs and symptoms of hypo/[MEDICAL CONDITION] beginning [DATE]. 2. Inservice all nurses regarding notification of physician if resident is admitted /readmitted with [DIAGNOSES REDACTED]. 3. Inservice all nurses regarding potential adverse effects of hypoglycemic medications beginning [DATE]. *All inservices for CNA's and nurses begun immediately on [DATE]. All inservices for scheduled full time employees will be completed by [DATE]. Part time and PRN (as needed) employees will be inserviced prior to their next scheduled shift. Inservice for CNA's and nurses will be added to new employee orientation packet immediately beginning [DATE] to ensure education is provided before working with the residents. 4. Nurse Manager will audit all admit and readmit charts for [DIAGNOSES REDACTED]. 5. Compliance with current residents will be achieved on [DATE]. The Immediate Jeopardy was removed on [DATE] at 4:55 p.m. when the surveyor confirmed all residents' records were reviewed for blood glucose monitoring. The deficient practice remains at a level 3, potential for harm for Resident #8. Findings: A review of the facility's Policy and Procedure entitled Care of the Diabetic Resident revealed the following: Policy: It is the policy of ________ to ensure that all residents diagnosed with [REDACTED]. Every effort will be made to prevent residents from hyperglycemic or hypoglycemic episodes. Procedure: 1. Assess level of blood sugar by glucometer check. This may be done once a day or up to four (4) times daily and may also be done on an as needed basis, depending on the physician's orders [REDACTED]. 3. If the blood sugar is below sixty (60) or greater than 400 then notify the physician unless otherwise stated in doctor's orders. 11. All residents on diabetic monitoring must have a Diabetic Monitoring Flowsheet in their medical record. This must be filled in accurately and appropriately. 12. The Director of Nursing or her designee will monitor routinely to make certain that residents are being monitored on a regular basis. She will report findings to the Quality Assurance Committee. Resident #2 A review of the medical records on [DATE] from the local hospital revealed the following: admitted : [DATE] discharge date : [DATE] Discharge Summary stated the following: Final Diagnoses: [REDACTED]. Hx (History) of [MEDICAL CONDITION] and behavioral disturbances. 2. Hx of [MEDICAL CONDITION]. 3. [MEDICAL CONDITION]. History of Present Illness: This patient is a [AGE] year old male transferred from __________a local hospital for altered mental status. He lives in nursing home became angry, was then behavioral disturbances. He was admitted to the hospital. He was ruled out for any metabolic issues. The patient is medically stable to be discharged to inpatient psychiatric facility. A review of the medical records from the inpatient psychiatric facility revealed the following: Admit: [DATE] Discharge: [DATE] back to nursing home Resident was receiving [MEDICATION NAME] 2 mg by mouth twice a day in inpatient psychiatric facility as well as Accuchecks four times a day. A review of the facility's clinical record revealed the following: Resident #2 was a [AGE] year old male and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A review of the physician orders [REDACTED]. Diagnoses: [REDACTED].>Glimepiride ([MEDICATION NAME]) 2 mg 1 tab PO (by mouth) twice daily for diabetes - 8:00 a.m., 4:00 p.m. A review of the care plan revealed the following: Problem: Potential for altered tissue perfusion and impaired metabolism related to Diabetes (Onset [DATE]) Goal and target date: Resident will be free of all s/s (signs and symptoms) of hypo/[MEDICAL CONDITION] over the next 90 days ,[DATE] Approaches: Administer medication as ordered: [MEDICATION NAME], Assess skin integrity daily with care and report any abnormalities, Monitor weights every month per MD (Medical Doctor) orders and facility protocol, Monitor level of activity, Conduct a comprehensive nursing skin inspection weekly, Assess environment for safety hazards, Avoid injuries related to decreased sensation (Neuropathies), Provide following diet: Cardiac 1800 ADA (American Diabetic Association) diet There were no specific approaches to monitor the signs and symptoms of hypo/[MEDICAL CONDITION]. A review of the social worker note revealed the following: [DATE] at 3:20 p.m. - He has had a decline in his mental status. He displayed a hallucination. He asked SSD (social service director) to move the snake on his bed. SSD reassured him that there was not a snake on his bed. SSD also informed his nurse on today of the hallucination. A review of the nurse's notes revealed the following: [DATE] at 7:20 p.m. - Resident arrived at facility from __________Behavioral Health Center in Houma, LA with Dx (Diagnosis) of CAD ([MEDICAL CONDITION]),[MEDICAL CONDITION](Hypertension), DM (Diabetes), and Cardiac Arrhythmia. Resident was awake and oriented. Skin W/D (Warm/Dry) to touch. Respiration even and nonlabored. Propels himself in w/c (wheelchair) has good mobility .Transfers independently uses w/c for ambulation. [DATE] at 8:00 p.m. - Up in wheelchair in hallway, no s/s of distress noted, increase confusion noted. (Signed by S4LPN) A review of the resident's clinical record revealed there was no documentation the physician or responsible party was notified. [DATE] at 9:30 a.m. - Sitting up to w/c alert, engages in conversation confused, disoriented. Not easily redirected. Speech slurred and difficult to understand at times. (Signed by S3LPN) There was no documentation the physician or responsible party was notified. [DATE] at 8:00 p.m. - Resident lying in bed with eyes closed not easily aroused, very lethargic, attempted to arouse resident for med administration without success, came back at 8:45 p.m. for a second attempt to give meds, resident found to be having apneic episodes and completely unresponsive, all attempts to arouse failed. V/S ,[DATE], 83, 96.5, respirations uneven and labored, CBG (Capillary Blood Glucose) -26, R/P (Responsible Party) alerted to current situation and agreed to send out to ER at RMC at 9:05 p.m., called EMS at 9:10, notified RMC ER at 9:12 p.m., EMS (Emergency Medical Service) arrived for transport of resident to the local hospital at 9:20 p.m. (Signed by S4LPN) There is no documentation the physician was notified. A review of the local EMS (emergency medical service) company records revealed the following: [DATE] Call received: 2111 (9:11 p.m.) Respond: 2112 (9:12 p.m.) On Scene: 2114 (9:14 p.m.) Leave Scene: 2131 (9:31 p.m.) At hospital: 2137 (9:37 p.m.) Reason for Call: Unconscious/[MEDICAL CONDITION] Clinical Impression: [DIAGNOSES REDACTED] - CBG (Capillary Blood Glucose), Unresponsive Called to the scene above for an unresponsive patient. Per nurse no one knows if that patient has eaten all day. No one knows when the last time the patient was responsive. Per nurse, they believed the patient was just sleeping all day. Patient was found supine in bed, pale, cool to touch, unresponsive, snoring respirations at 6. Per nurse, patient is diabetic, but no orders to maintain or check levels of blood sugar. Patient was moved to stretcher via draw sheet and secured with safety belts x 3. Patient was loaded into unit and secured. Vitals were taken, CBG at 20. IV accessed, 25 g D ([MEDICATION NAME]) 50% given IV (Intravenous). Patient still snoring respirations with periods of apnea. Patient was ventilated en route via BVM (Bag Valve Mask), due to snoring respirations at 8, and low O2 (oxygen) sats (saturations) below 90%. EMS found DNR (Do Not Resuscitate) en route, EMS was not notified by nurse that patient was DNR. Ventilations terminated due to DNR. Patient ' s pupils were dilated and unresponsive. Patient had no response to pain en route. Patient was monitored en route with no changes or improvements. Patient was left on O2 15 lpm (liters per minute) NRB (Non Rebreather Mask). Patient has a fresh scar to top left chest (no report of what it is from nurse). Patient maintained a strong pulse and good blood pressure en route. Report called to ________ a local hospital emergency room . Patient moved to hospital bed via draw sheet. A review of medical records from ___________ a local hospital revealed the following: Registered: [DATE] at 9:34 p.m. discharged : [DATE] at 1:24 a.m. ED (Emergency Department) Physician note on [DATE] at 9:54 p.m. revealed the following: Associated Diagnoses: [REDACTED].>Time seen: Immediately upon arrival. History source: EMS Arrival mode: Ambulance History limitation: unresponsive History of Present Illness: The patient presents with [DIAGNOSES REDACTED]. The onset was just prior to arrival. The blood sugar was 26 mg/dL. Risk factors consist of diabetes mellitus, hypertension and [MEDICAL CONDITION]. Prior episodes: none. Therapy today: intravenous [MEDICATION NAME]. Patient sent from NH (nursing home) with unresponsive, as per NH (nursing home) staff patient did not eat all days and he was sleeping most of the days, this evening staff was unable to wake up patient. Review of System: Patient is unresponsive. Vital Signs: [DATE] at 2138 Temperature Axillary: 36.5 Degree Celsius, Peripheral Pulse Rate: 78 bpm (beats per minute), BP ,[DATE], SpO2 99%, Oxygen Flow Rate: 15 L/min, Oxygen Therapy: Nonrebreather mask Blood Glucose, Capillary, POC (Point of Care) - [DATE] at 10:45 p.m. 54 mg/dL Low [DATE] CT of head - no acute findings. Impression and Plan: Diagnosis: [REDACTED]. Calls - Consult - [DATE] at 12:38 a.m., case discussed with another physician - accepted patient for transfer at ____________another local hospital. Plan - Family, lab results discussed with Patient's family at bedside. Family is requesting to go to a different facility because he has been at the local hospital twice recently. [DATE] at 10:32 p.m. Chest X-Ray revealed the following: Clinical Information: [DIAGNOSES REDACTED]. Patient unresponsive. Impression: There is no acute cardiopulmonary disease. Blood Chemistry lab [DATE] at 9:50 p.m. glucose 90 A review of the medical records from ____________ a local hospital #2 revealed the following: Discharge Summary: admitted : [DATE] discharged : [DATE] Final Diagnoses: [REDACTED]. Severe metabolic [MEDICAL CONDITION]. 2. [DIAGNOSES REDACTED] 3. Acute [MEDICAL CONDITION]. 4. [MEDICAL CONDITION]. 5. History of pacemaker. 6. Hypertension 7. Diabetes 8. Chronic [MEDICAL CONDITION] 9. History of [MEDICAL CONDITION] 10. [MEDICAL CONDITION] 11. [MEDICAL CONDITION] 12. [MEDICAL CONDITION] History of Present Illness: The patient was a [AGE] year old resident of ________Nursing Home, transferred to __________ a local hospital for evaluation of [DIAGNOSES REDACTED]. The patient ended up at this hospital with altered mental status, [MEDICAL CONDITION], and [MEDICAL CONDITION].[MEDICAL CONDITION] was ruled out. He was a DNR, on comfort measures only per family. He was pronounced dead on [DATE] at 4:55 p.m. On [DATE] at 9:29 a.m. a telephone interview was conducted with the resident's responsible party, his daughter. She stated her father returned to the facility from the last hospital visit on [DATE] at about 7:30 p.m. She stated the next day ([DATE]) S5SSD told her that her father asked her to get snakes out of his bed. She stated S5SSD also informed her that her father's nurse told her earlier that her father was confused and asked her to get the old man eating cookies out of his bed. She stated she called the facility to check on her father the same day and the staff reassured her he was fine. She stated she was never informed of his confusion, or hallucination by the nursing staff. On [DATE] at 10:36 a.m. an interview was conducted with S6CNA. She stated she had been working at the facility for 3 years. She stated she was very familiar with Resident #2's care. She stated when he first came he was independent and later on he needed assistance. She stated he could feed himself and his appetite was fair. She stated his daughter, and wife would visit him. She stated he could speak clearly. S6CNA stated he smoked a lot and sometimes he would wheel himself out to smoke. She stated when had confusion she would report it to his nurse S2LPN. She stated he would get agitated at times but he was cooperative with care. On [DATE] at 10:53 a.m. an interview was conducted with S5SSD. She stated she worked at the facility for 3 years. She stated she was very familiar with Resident #2. After reviewing her progress note dated [DATE] at 3:20 p.m. she stated the resident asked her to remove the snake on the bed. She stated she told the S2LPN on [DATE] around 3:15 p.m. She stated she clearly remembered the incident because S2LPN was on med pass and her cart was right in front of her office when she told her about his hallucination. She stated S2LPN informed her that he asked her to move the man in his room. She was asked if Resident #2 ever had slurred speech. S5SSD stated he had very clear speech and it wasn't until that time when he started to decline. She stated the wife and daughter would be very involved. She stated the responsible party was his daughter. She stated she told the daughter about the hallucination and she was very surprised. She stated, She acted like oh really! On [DATE] at 11:27 a.m. an interview was conducted with S2LPN. She stated she was very familiar with Resident #2. She was asked how did she know a diabetic resident needed Accuchecks (glucose monitoring). She stated, We usually go by the physician orders. She stated we can check it as needed if there was no order. She stated when he first came to the facility he was alert, oriented and he could walk a short distance. She stated after a couple of months we caught him smoking in facility and we had to take his cigarettes. She stated he would be sitting outside on the porch and falling asleep. Staff would try to get him to go to bed and he refused. He would go to bed when he was ready. She stated he had trouble sleeping at night. She stated he feed himself. She stated the CNAs would report any change in appetite to the nurse. She was asked if she ever checked his blood glucose. She stated he would ask her periodically to check his sugars. She stated, I think he was curious. She stated she would write the Accucheck on the back of the MAR (Medication Administration Record). She was asked if she documented any sugar checks on the back of the MAR. After reviewing the clinical record, she stated, I don't see it, No. She stated she used the diabetic flow sheet if the resident was on scheduled Accuchecks. She stated she didn't see one of those in the record. She stated it was usually like 120s and didn't require any coverage. She stated, the resident usually asked her before supper to check his sugar. She stated he was admitted with [MEDICATION NAME]. She stated she didn't remember Resident #2 ever having hallucinations. She was asked what would she do if the resident had a hallucination. She stated she would report hallucinations to the doctor. After she reviewed the nursing care plans she was asked if there were any specific interventions to monitor for signs and symptoms of hypo/[MEDICAL CONDITION]. She stated, No. On [DATE] at 12:04 p.m. an interview was conducted with S3LPN. She stated she was the nursing station manager. She was asked how did the staff know when to perform an Accucheck on a diabetic resident. She stated, We go by the physician orders, if there are no orders for accu checks then we don't check it unless we see a need to check it. She stated if we did not have an order and resident was on [MEDICATION NAME] we did not check the sugar unless the resident was lethargic, sweating, clammy, cool to touch, or had confusion. She stated if Accuchecks were not ordered then it won't be documented unless it was a problem and we needed to contact the physician. She was asked what was the facility's protocol for taking Accuchecks on diabetic residents. She stated there was no protocol for accuchecks, we just follow the physician orders. She stated she was familiar with Resident #2. She stated every now and then he would want the staff to check his sugars. She was asked if anyone contacted the physician to see if he wanted accuchecks done on the resident. She stated, If he wasn't on accuchecks then we don't ask for them to be placed on accuchecks. She confirmed the nursing notes did not consistently document confusion, disorientation and slurred speech as his usual state. After reviewing the clinical record she confirmed there was no documentation of an accucheck or that the physician was notified of his confusion, disorientation or slurred speech on [DATE] at 9:30 a.m. After further review of the medical record she confirmed there was no documentation of the resident ' s status from [DATE] at 9:30 a.m. until [DATE] at 8:00 p.m. when he was found in his bed lethargic and could not be aroused. After reviewing the care plan, she was asked if there were any specific interventions to monitor for signs and symptoms of hypo/[MEDICAL CONDITION]. She stated, No. On [DATE] at 1:16 p.m. an interview was conducted with S4LPN. She stated she was familiar with Resident #2. She stated before the resident went out to the psych facility he was self sufficient. She stated when he came back he changed. She stated he would skip meals and it was reported during shift change. She explained the skipped meals wasn't charted usually just reported during shift change. She stated the nurse would receive the information from CNAs. She stated he usually missed his dinner meal. She stated she did remember him refusing snacks. She was asked when did she perform accuchecks on diabetic residents. She stated it depends on the physician orders [REDACTED]. She stated if there was no order she would call the physician to clarify. She stated he was not getting accuchecks. She was asked to explain the events that occurred on [DATE]. She stated on [DATE] at 6:00 p.m. he was in room in bed and snoring. She said, He was doing the same thing as the day before, he was out of it, lethargic. She stated she was told in report that he ate his breakfast, half his lunch and skipped dinner. She stated, she clearly remembers that he did skip dinner that night. She stated she was starting med pass at 6:30 p.m. and got to him around 7:00 p.m., she stated he was easily aroused, she shook him, and he moaned. She stated before she went to the back hall to complete her med pass at about 8:20 or 8:30 p.m. she went back to him and he was more lethargic and noticed he wasn't breathing right. She stated he had Kussmaul breathing, and she took his vital signs. She stated his vital signs were stable then she checked his glucose and it was 26. She was asked if she notified the physician the first time she found the resident lethargic. She stated, No, because I didn't know of the nurse before me had already informed the physician. She was asked if she notified the physician of the second time when the resident was found to be having apneic episodes and completely unresponsive. She stated, No, we usually send a fax sheet to the MD. She stated she notified the resident's daughter. On [DATE] at 1:39 p.m. a telephone interview was conducted with the EMT (emergency medical technician). He stated he did recall transporting Resident #2 from the facility to a local hospital. He was asked to describe the situation when he arrived to the facility. He stated when he arrived on the scene he found the resident lying in bed snoring with respirations 6. He stated when he arrived at the facility he was told the patient was sleeping all day, and staff assumed patient was tired all day. When he was en route to hospital he found out through the paperwork the patient was a DNR. He stated the patient had a recent surgical wound to his chest area but the nursing staff did not tell him what type of surgery he had. He stated he took CBG (capillary blood glucose) in route and it was 20. He stated the nursing staff never informed him that the patient's glucose was 26. He explained that he would have started the D50 sooner. He stated the nurse told him she did not take a blood sugar because there were no orders to do it. On [DATE] at 2:32 p.m. an interview was conducted with S1DON. She was asked how did the staff know when to perform an accucheck on a diabetic resident. She stated accuchecks were done per physician orders. She the nurse would also perform an accucheck if the resident had sign/symptoms of [DIAGNOSES REDACTED] or if a resident requested the accucheck to be done. If accu checks were on the routine physician orders [REDACTED]. She stated she and the assistant director of nursing would make sure the residents accuchecks were being done and they were going by the physician orders. She was asked if an incident and accident report was completed for Resident #2. She stated, No, an incident and accident report was not done on [DATE] for Resident #2 because we didn't feel there was a problem. After reviewing the nurses' notes she confirmed there was no documentation by the nursing staff of the resident's hallucination or that the physician or responsible party was notified. She also confirmed there was no nursing note notifying the physician or responsible party of the resident's confusion, disorientation or slurred speech on [DATE] at 9:30 a.m. She explained, If someone never had hallucinations and suddenly has hallucinations then there would be issue She confirmed there was no nursing note of the resident's status from [DATE] at 9:20 a.m. until 8 p.m. when he was found in his bed lethargic and could not be aroused. After reviewing the care plan, she was asked if there were any specific interventions to monitor for signs and symptoms of hypo/[MEDICAL CONDITION]. She stated, No. On [DATE] at 8:58 a.m. a telephone interview was conducted with S10MD. He stated he was the primary physician for Resident #2. He confirmed Resident #2 was a diabetic and was taking [MEDICATION NAME] 2mg PO (by mouth) twice a day. He was asked how often should the nursing staff have been checking his blood glucose level. He stated, Four times a day, AC (before meals) and HS (at bedtime). He stated if a diabetic resident on medication did not have an order for [REDACTED]. He stated, No, he was very articulate. He was asked if Resident #2 ever had hallucinations. He stated, No. Surveyor read out load to S10MD the social worker note dated [DATE] at 3:20 p.m. wherein the resident told the social worker to get the snake out of his bed and the social worker informed the nurse about the hallucination. He was asked if he should have been notified of the hallucination. He stated, Yes. Surveyor read out loud to S10MD the nursing note dated [DATE] at 8:00 p.m. He was asked if the resident had an increase in confusion should he have been notified. He stated, Yes. Surveyor read out loud to S10MD the nursing note dated [DATE] at 9:30 a.m. Sitting up in wheelchair, alert, engages in conversation. Confused/disoriented. Not easily redirected. Speech slurred and difficult to understand at times. He was asked if he would expect the nursing staff to perform an accucheck on the resident. He stated, Yes. He was asked if he would expect the staff to notify him of the resident's condition on [DATE] at 9:30 a.m. He stated, Yes. He was asked if he was notified on [DATE] at 8:00 p.m. when the resident was found in bed with eyes closed, not easily aroused, and very lethargic. He stated, No. Resident #8 Review of the clinical record revealed Resident #8 was an [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. [MEDICATION NAME] 4 mg (milligrams) p.o. (by mouth) daily for Diabetes (start date: [DATE]) [MEDICATION NAME] 100 mg p.o. daily for Diabetes (start date: [DATE]) Basic Metabolic Panel - January, May, September HgbA1C Q (every) 3 months - January, May, September Review of the MAR (medication administration record) for March, April, and [DATE] revealed the resident received [MEDICATION NAME] 4 mg and [MEDICATION NAME] 100 mg p.o. daily. There was no documentation of routine accuchecks performed on the resident. Review of lab tests performed on [DATE] revealed the following results: HgbA1C - 7.9 (High). Reference range 4XXX,[DATE].5 Glucose Level - 136 (High). Reference range ,[DATE] Review of a Quarterly MDS (Minimum Data Set), with ARD (Assessment Reference Date) of [DATE], revealed the following: Section C (Cognitive Patterns) - BIMS (Brief Interview for Mental Status) score 15, cognitively intact. Section I (Active Diagnoses) - included Diabetes Mellitus Section K (Swallowing/Nutritional Status) - Therapeutic diet On [DATE] at 11:11 a.m., an observation of Resident #8 was performed. He was observed lying in his bed. He was awake, alert, and oriented. On [DATE] at 11:12 a.m., an interview was conducted with resident #8. He stated he became a resident at the facility in August of 2015. Resident #8 further stated he was a diabetic and has taken diabetic medications for at least [AGE] years. Resident #8 verified he was taking daily medicines by mouth for diabetes. He was asked if he checked his blood sugars at home before entering the facility. He stated, Yes. Resident #8 was asked if the facility's staff checked his blood sugars routinely. He stated, No. On [DATE] at 11:22 a.m., an interview was conducted with S8LPN. She stated she had worked at the facility for 3 years. S8LPN verified Resident #8 was a diabetic. She further verified Resident #8 takes [MEDICATION NAME] and [MEDICATION NAME] daily. S8LPN was asked if routine accuchecks were performed on Resident #8. She stated no routine accuchecks were performed on the resident. On [DATE] at 11:47 a.m., a telephone interview was conducted with S9MD. He verified he was Resident #8's primary physician. He further verified the resident was a diabetic. After reviewing the resident's medications with him and the lab results of an increased HgbA1C and increased blood glucose level on [DATE], S9MD was asked if any routine accuchecks should have been conducted on Resident #8. S9MD stated he would have expected Resident #8 to receive accuchecks daily, or at the very least, weekly to monitor his blood glucose levels, especially with a HgbA1C level of ,[DATE].

Based on interviews and record reviews the facility failed to immediately inform the resident's physician, or legal representative of a significant change of condition for 1(Resident #2) of 8 (Resident #1, #2, #3, #4, #5, #6, #7, #8) sampled residents. The facility further failed to notify the resident's physician that there was no order for blood glucose checks for 2 (#2, #8) of 2 (#2, #8) residents receiving [MEDICATION NAME] (a medication to help control blood sugar levels) of a sample of 8 diabetic residents (#1, #2, #3, #4, #5, #6, #7, #8). Resident #2 was placed in Immediate Jeopardy on [DATE] when the he was found to be confused, and hallucinating. On [DATE] at 9:30 a.m. he was not easily redirected and had slurred speech. At 8:00 p.m., the same evening, he was in his bed with his eyes closed, lethargic and could not be aroused. At 8:45 p.m. he was found with apnea episodes and completely unresponsive with a blood glucose level of 26. The legal representative was not informed of the resident's change of condition until [DATE] at 9:20 p.m. Resident #2 was transferred to a local hospital on [DATE] at 9:20 p.m. The Administrator was notified of the Immediate Jeopardy situation on [DATE] at 1:55 p.m. A plan of removal was presented by the Administrator which read as follows: 1. Resident #2 expired in hospital in March, 2016. 2. Any diabetic resident taking oral hypoglycemic agents who is not on routine blood sugar monitoring has the potential to be affected by alleged deficient practice. A. Facility will immediately identify all current residents taking oral hypoglycemic who not have routine accucheck orders and notify MD (Medical Doctor) for further orders. 3. To ensure deficient practice does not recur, the facility will: 1. All residents who are admitted or readmitted to the facility with a [DIAGNOSES REDACTED]. 4. To ensure solutions are sustained the facility will: 1. Inservice all Nurses and CNA's (Certified Nursing Assistants) on signs and symptoms of hypo/[MEDICAL CONDITION] beginning [DATE]. 2. Inservice all nurses regarding notification of physician if resident is admitted /readmitted with [DIAGNOSES REDACTED]. 3. Inservice all nurses regarding potential adverse effects of hypoglycemic medications beginning [DATE]. *All inservices for CNA's and nurses begun immediately on [DATE]. All inservices for scheduled full time employees will be completed by [DATE]. Part time and PRN (as needed) employees will be inserviced prior to next scheduled shift. Inservice for CNA's and nurses will be added to new employee orientation packet immediately beginning [DATE] to ensure education is provided before working with the residents. 4. Nurse Manager will audit all admit and readmit charts for [DIAGNOSES REDACTED]. 5. Compliance with current residents will be achieved on [DATE]. The Immediate Jeopardy was removed on [DATE] at 4:55 p.m. when the surveyor confirmed all residents' records were reviewed for any change in condition and proper responsible party and physician notification. The deficient practice remains at a level 3, potential for actual harm for Resident #8. Findings: A review of the facility's document entitled, Policy and Procedure Condition Change, of the Resident (Observing, Recording and Reporting) revealed the following: Purpose: To observe, record and report any condition change to the attending physician so proper treatment will be implemented. Procedure: 1. After all resident falls, injuries or changes in physical or mental function, monitor the following: e. Observe for personality changes. f. Observe for alterations in consciousness. h. Observe for sensory weakness. i. Observe for generalized weakness. m. Observe for proper reflexes (response to painful stimuli). q. Observe for unequal pupils. r. Observe for dyspnea or variations in respirations (irregular). s. Observe for flushing or cyanosis. t. Observe for pain. 2. Have someone stay with the resident while the nurse is calling the attending physician, if necessary. If you are unable to reach the attending physician or the physician on call, call the facility medical director. 3. Complete an incident, accident or risk management report per facility policy. General Resident Care Plan Documentation Guidelines 1. Identify underlying problem causing the condition change. 2. Establish a measureable goal for resolution of the condition. 3. Develop a plan to treat the condition; observe and monitor resident's response to treatment. Preventive measures, safety measures and resident education. Observation and reporting of complications. 4. A decision to transfer or discharge the resident from the facility. Review of the clinical record revealed Resident #2 was a [AGE] year old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A review of the physician orders [REDACTED]. Diagnoses: [REDACTED].>Glimepiride ([MEDICATION NAME]) 2 mg 1 tab PO (by mouth) twice daily for diabetes - 8:00 a.m., 4:00 p.m. A review of the care plan revealed the following: Problem: Potential for altered tissue perfusion and impaired metabolism related to diabetes (Onset [DATE]) Goal and target date: Resident will be free of all s/s (signs and symptoms) of hypo/[MEDICAL CONDITION] over the next 90 days ,[DATE] Approaches: Administer medication as ordered: [MEDICATION NAME], Assess skin integrity daily with care and report any abnormalities, Monitor weights every month per MD (Medical Doctor) orders and facility protocol, Monitor level of activity, Conduct a comprehensive nursing skin inspection weekly, Assess environment for safety hazards, Avoid injuries related to decreased sensation (Neuropathies), Provide following diet: Cardiac 1800 ADA (American Diabetic Association) diet A review of the care plan revealed no specific approaches to monitor the signs and symptoms of hypo/[MEDICAL CONDITION]. A review of the social worker note revealed the following: [DATE] at 3:20 p.m. - He has had a decline in his mental status. He displayed an hallucination. He asked SSD (social service director) to more the snake on his bed. SSD reassured him that there was not a snake on his bed. SSD also informed his nurse on today of the hallucination. A review of the nurse's notes revealed the following: [DATE] at 8:00 p.m. - Up in wheelchair in hallway, no s/s of distress noted, increase confusion noted. (Signed by S4LPN) There was no documentation the physician or responsible party was notified. [DATE] at 9:30 a.m. - Sitting up to w/c alert, engages in conversation confused, disoriented. Not easily redirected. Speech slurred and difficult to understand at times. (Signed by S3LPN) There was no documentation the physician or responsible party was notified. [DATE] at 8:00 p.m. - Resident lying in bed with eyes closed not easily aroused, very lethargic, attempted to arouse resident for med administration without success, came back at 8:45 p.m. for a second attempt to give meds, resident found to be having apneic episodes and completely unresponsive, all attempts to arouse failed. V/S ,[DATE], 83, 96.5, respirations uneven and labored, CBG (Capillary Blood Glucose) -26, R/P (Responsible Party) alerted to current situation and agreed to send out to ER (emergency room ) _____a local hospital at 9:05 p.m., called EMS (Emergency Medical Service) at 9:10 p.m., notified the local hospital ______ER at 9:12 p.m., EMS arrived for transport of resident to the local hospital at 9:20 p.m. (Signed by S4LPN) There was no documentation the physician was notified. On [DATE] at 9:29 a.m. a telephone interview was conducted with the resident's responsible party, his daughter. She stated her father returned to the facility from the last hospital visit on [DATE] at about 7:30 p.m. She stated the next day ([DATE]) S5SSD told her that her father asked her to get snakes out of his bed. She stated S5SSD also informed her that her father's nurse told her earlier that her father was confused and asked her to get the old man eating cookies out of his bed. She stated she called the facility to check on her father the same day and the staff reassured her he was fine. She stated she was never informed of his confusion, or hallucination by the nursing staff. On [DATE] at 10:53 a.m. an interview was conducted with S5SSD. She stated she worked at the facility for 3 years. She stated she was very familiar with Resident #2. After reviewing her progress note dated [DATE] at 3:20 p.m. she stated the resident asked her to remove the snake on the bed. She stated she told the S2LPN on [DATE] around 3:15 p.m. She stated she clearly remembered the incident because S2LPN was on med pass and her cart was right in front of her office when she told her about his hallucination. She stated S2LPN informed her that he asked her to move the man in his room. She was asked if Resident #2 ever had slurred speech. She stated he had very clear speech and it wasn't until that time when he started to decline. She stated the wife and daughter would be very involved. She stated the responsible party was his daughter. She stated she told the daughter about the hallucination and she was very surprised. She stated, She acted like oh really! On [DATE] at 11:27 a.m. an interview was conducted with S2LPN. She stated she didn't remember Resident #2 ever having hallucinations. She was asked what would she do if the resident had a hallucination. She stated she would report hallucinations to the doctor. On [DATE] at 12:04 p.m. an interview was conducted with S3LPN. She confirmed the nursing notes did not consistently document confusion, disorientation and slurred speech as his usual state. After reviewing the clinical record she confirmed there was no documentation that the physician was notified of his confusion, disorientation or slurred speech on [DATE] at 9:30 a.m. After further review of the medical record she confirmed there was no documentation of the resident's status from [DATE] at 9:30 a.m. until [DATE] at 8:00 p.m. when he was found in his bed lethargic and could not be aroused. On [DATE] at 1:16 p.m. an interview was conducted with S4LPN. She was asked if she notified the physician the first time she found the resident lethargic. She stated, No, because I didn 't know if the nurse before me had already informed the doctor. She was asked if she notified the physician of the second time when the resident was found to be having apneic episodes and completely unresponsive. She stated, No, we usually send a fax sheet to the doctor. On [DATE] at 2:32 p.m. an interview was conducted with S1DON. After reviewing the nurses' notes she confirmed there was no documentation by the nursing staff of the resident's hallucination or that the physician or responsible party was notified. She also confirmed there was no nursing note notifying the physician or responsible party of the resident's confusion, disorientation or slurred speech on [DATE] at 9:30 a.m. She explained, If someone never had hallucinations and suddenly has hallucinations then there would be issue. She confirmed there was no nursing note of the resident's status from [DATE] at 9:20 a.m. until 8 p.m. when he was found in his bed lethargic and could not be aroused. On [DATE] at 8:58 a.m. a telephone interview was conducted with S10MD. He stated he was the primary physician for Resident #2. He confirmed Resident #2 was a diabetic and was taking [MEDICATION NAME] 2mg PO (by mouth) twice a day. He stated if a diabetic resident on medication did not have an order for [REDACTED]. He stated, No, he was very articulate. He was asked if Resident #2 ever had hallucinations. He stated, No. Surveyor read out load to S10MD the social worker note dated [DATE] at 3:20 p.m. wherein the resident told the social worker to get the snake out of his bed and the social worker informed the nurse about the hallucination. He was asked if he should have been notified of the hallucination. He stated, Yes. Surveyor read out loud to S10MD the nursing note dated [DATE] at 8:00 p.m. He was asked if the resident had an increase in confusion should he have been notified. He stated, Yes. Surveyor read out loud to S10MD the nursing note dated [DATE] at 9:30 a.m. Sitting up in wheelchair, alert, engages in conversation. Confused/disoriented. Not easily redirected. Speech slurred and difficult to understand at times. He was asked if he would expect the nursing staff to perform an accucheck on the resident. He stated, Yes. He was asked if he would expect the staff to notify him of the resident's condition on [DATE] at 9:30 a.m. He stated, Yes. He was asked if he was notified on [DATE] at 8:00 p.m. when the resident was found in bed with eyes closed, not easily aroused, and very lethargic. He stated, No.

Based on observations, interviews and record review, the facility failed to ensure the residents receive adequate supervision to prevent falls for 2 (Resident # 2, #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5) sampled residents. Resident #2 was severely impaired, had a [DIAGNOSES REDACTED]. The resident experienced a fall on 07/06/15. Resident #5 was severely impaired residents, had muscle weakness, balance disturbance, gait disturbance, and was at high risk for falls. The resident experience falls from her wheelchair on 07/02/15, 08/07/15, 08/09/15, 08/10/15 and 08/11/15. This failed practice resulted in an actual harm for Resident #2 on 07/06/15 at 4:00 p.m. when Resident #2 who was found on the floor after being left unattended in a reclining wheelchair that was missing a left armrest. The resident was transferred to the hospital after the fall. Review of the local hospital emergency room documentation dated 07/06/15 revealed Resident #2 had a Frontal Sinus Fracture, Frontal Skull Fracture, Closed C1 Fracture and Pleural Effusion. The resident was transferred to another hospital for further evaluation and treatment. His [DIAGNOSES REDACTED]. Findings: Resident #2 A review of the clinical record revealed Resident #2 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He was blind in the right eye and had poor vision to the left eye. A review of the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/06/15 revealed the following: Section C (Cognitive Patterns) - he was moderately impaired -decisions poor, cues/supervision required; Section G (Functional Status) - the resident required total dependence with two person physical assist with bed mobility, and transfer. He required total dependence with one person physical assist with locomotion on and off the unit. His mobility devices consisted of a wheelchair; Section O (Special Treatments, Procedures and Programs) - he received Speech-language, Occupational and Physical Therapy; Section V (Care Area Assessment (CAA) Summary revealed he had a BIMS (Brief Interview for Mental Status) score of 7 dated 06/30/15 - 07/06/15 which indicated he was severely cognitively impaired. A review of the physician's order [REDACTED]. Fall Precaution Dialysis Monday - Wednesday - Friday OT (Occupational Therapy) treatment for [REDACTED]. PT (Physical Therapy) evaluate and treat for 5 times a week for 14 weeks for treatment [DIAGNOSES REDACTED]. ST (Speech Therapy) evaluate and treat for up to 84 visits in 14 weeks for treatment [DIAGNOSES REDACTED]. 07/06/15 Send to ER for evaluation and treatment related to Fall A review of the Fall Risk assessment dated [DATE] revealed a total score of 16 which indicated the resident was a High Risk. Review of the Incident and Accident Reporting Form for Resident #2 dated 07/06/15 revealed the following: Date of Incident - 07/06/15; Time of Incident 4:00 p.m.; Location of incident/accident - Resident ' s Room; Describe exactly what happened - Found on floor in room between bed and wheelchair in prone position with moderate amount of blood on floor coming from left forehead.; Witness(es) - S5CNA, S6CNA, S4LPN, and S3ADON. Review of the Fall Evaluation dated 07/6/15 at 4:00 p.m. revealed the following: Fall History - one fall/isolated event; Risk Factors - new admission (within 2 weeks), medication changes (within 30 days), receives more than 5 medications; Description of fall - from wheelchair or chair, assistive devices - reclining wheelchair; Location of Fall - room; Type of Injury - hematoma; Site of Injury - head; Description of Injury - hematoma (half dollar sized) to left forehead; Resident ' s account of Occurrence - states, I was trying to get up. ; Review of the Neurological Assessment revealed the following: 1) Unable to assess pupil reaction due to resident ' s position on floor; 2) complaints of mild pain to forehead, talking calmly to staff, no yelling or guarding noted, denies nausea. Review of the documented statement of S5CNA, revealed the following: I went into Resident #2 ' s room and he was still in his chair. I put a gown on him and came to get help to put him in the bed. When I got back to his room he was on the floor. When I left the room resident was reclined back and positioned comfortably. Review of the documented statement of S11DR, revealed the following: Brought Resident #2 back to his room after dialysis at approximately 3:20 p.m. When I left him in his room, his wheelchair was in the recline position. Review of the documented statement of S3ADON, revealed the following: .Upon entering the room, observed Resident #2, lying on floor, in prone position, next to his reclining wheelchair (still in reclined position). Moderate bleeding noted that appeared to be coming from the left side of his forehead and possibly a small amount from the left nostril. Review of the documented statement of S2DON revealed the following: .Upon entering room, found Resident #2 face down in prone position between bed and reclined wheelchair. Moderate amount of blood on floor which appeared to be coming from left forehead. Resident #2 was answering questions appropriately and when asked how he fell stated, I was trying to get up to go to bed. .Once in supine position, able to assess half dollar sized hematoma to left forehead . Review of the Transportation Log revealed Resident #2 left the facility at 8:55 a.m. and returned to the facility on 3:22 p.m. Review of the maintenance repair log dated 07/07/15 revealed the following: Reported By: S3ADON Location: Arm rest missing off reclining wheelchair. Tagged out 07/06/15 and placed in maintenance closet. Review of the nursing notes revealed the following: 07/06/15 at 4:00 p.m. - Called to room by CNA. Found resident in prone position, head down on floor. Noted moderate amount of blood on floor coming from left side of forehead. Awake and asking staff to please turn him over. CNA states he was sitting in wheelchair next to bed, she left out of room to obtain another CNA to help put him to bed and when she returned to room with other CNA he was on the floor. A local emergency medical service was immediately notified for transport. Temperature 97.1, Pulse 99, Respirations 18, Blood Pressure 108/74. (signed by S2DON) 07/06/15 at 4:05 p.m. revealed the following: Called to room by overhead page upon entering room resident in prone position on stomach with moderate amount of blood noted on floor and face. Resident was between his bed and his wheelchair. Resident stated he was trying to go to bed. Resident answering simple questions appropriately. Instructed CNA ' s to not move resident until EMTs arrived to move resident. Resident was asking staff to roll him over but explained to him we would not be able to do so until ambulance arrived. (signed by S4LPN) 07/06/15 at 4:10 p.m. - The local emergency medical service here for transport. Medics rolled resident from prone position to supine. Half dollar sized hematoma noted to left forehead. Asked resident how he fell . States, I was trying to get up. Transferred to stretcher. Left with EMS in stable condition in route to a local hospital ER. (signed by S2DON) A review of the physical therapy note dated 07/01/15 revealed the following: Patient has difficulty reaching out and returning to midline safely and requires assistance with task. Tilt in space reclining wheelchair recommended at this time until patient develops more core stability and stamina to sit upright in a manual w/c for extended periods of time. Patient will be traveling by van 3 times a week to and from dialysis in a wheelchair, therefore, a reclining wheelchair is a safer option at this time. A review of the physical therapy plan of care dated 07/02/15 revealed the following: Reason for Referral: Recent hospitalization resulting in a decrease in strength, balance and endurance. Precautions: Poor balance, Low endurance Initial Assessment revealed the following: Functional Deficits: Balance, Fall Risk - high risk Balance, Fall Recovery - severely impaired Current level of function: The patient demonstrates sitting balance of Poor Plus (on Physical Therapy gradient scale) dynamic and tolerates for 30 seconds to 1 minute requiring moderate assistance. The patient is able to safely transfer from bed to wheelchair requiring maximum assistance x 2. A review of the OT plan of care dated 07/01/15 revealed the following: Reason for Referral: Recent hospitalization resulting in decrease in self- care. Precautions: Poor balance, Low endurance Initial Assessment revealed: Strength, Right Upper Extremity: 2/5 which indicated poor strength Strength, Left Upper Extremity: 2/5 which indicated poor strength A review of the OT Note dated 07/02/15 revealed the following: .Recommend positioning in tilt in space reclining wheelchair for pressure reduction, and improved trunk control during transport. Review of the local hospital emergency documentation dated 07/06/15 revealed the following: Impression and Plan: Frontal sinus fracture, Frontal skull fracture, Closed C1 fracture and Pleural Effusion. Addendum: Another local hospital was contacted and the neurosurgeon agreed to accept patient in transfer for further evaluation and treatment. Review of the Computed Tomography (CT) revealed the following: Exam Date / Time - 07/06/15 at 5:48 p.m.; Procedure - CT Spine Cervical without contrast ; Impression - Jefferson type fracture of the C1 vertebra with fractures of the bilateral anterior C1 ring and left posterior C1 ring with fracture of the left lateral mass of C1. There is lateral displacement of the C1 lateral masses . Review of the Computed Tomography revealed the following: Exam Date / Time - 07/06/15 at 5:48 p.m.; Procedure - CT Maxillofacial without contrast; Impression - 1. Nondisplaced fracture of the left frontal bone extending through the left frontal sinus with nondisplaced fracture of the anteromedial wall of the left orbit. Hemosinus demonstrated. 2. Fracture of C1 ring. Review of the Computed Tomography revealed the following: Exam Date / Time - 07/06/15 at 5:49 p.m.; Procedure - CT Head or Brain without contrast; Impression - 1. No acute intracranial abnormality is identified. 2. Involutional changes noted. Chronic ischemic changes noted. 3. There is left frontal scalp soft tissue swelling and hematoma with underlying left frontal bone fracture which extends across the walls of the left frontal sinus and also involves the medial wall of the left orbit anteriorly. On 08/12/15 at 1:43 p.m. an interview was conducted with S9PT. She stated the resident was in a tilt wheelchair for transport to dialysis. She stated she never saw him try to get up out the wheelchair and was surprised to learn that he tried to get out of the chair. She explained he was not very motivated and needed a lot of encouragement. She stated the therapist would need to stay with him to keep him on task, and verbally cue him. She was asked if physical therapy did any teaching with the CNAs for his transfer. She stated the resident was a max assist with two people. She stated he could assist us with transfers. She explained we were doing 75% to 100% with the transfer. She stated he had a lot of weakness. She stated we never used a slide board with him. She stated he was a very small man and didn ' t require a Hoyer lift. She stated she never had to teach the CNAs to take off the side rail of his wheelchair because he didn ' t require extra education for transfer. She stated he was just a regular two person transfer. She stated he wasn ' t a red flag patient such as hip precautions. On 08/12/15 at 2:08 p.m. an interview was conducted with S10OT. She stated he needed constant cueing and instruction on tasks. She stated he wasn ' t very active and responsive. He didn ' t take the initiative to move on his own. She stated she never saw him try to get out of his wheelchair and was very surprised to hear that he tried to get out of his chair. On 08/12/15 at 2:30 p.m. an interview was conducted with S3ADON. The Maintenance Work Order book was reviewed from May, 2015 until present. She verified the maintenance repair dated 07/07/15 was Resident #2 ' s wheelchair that was missing an arm rest. She explained she tagged it out on 07/06/15 and placed it in maintenance closet. She stated she noticed the missing left armrest after the incident occurred on 07/06/15. She stated the administrator had the Resident #2 ' s wheelchair in his office and it was taken out of service. On 08/12/15 at 2:45 p.m. an observation was made with S1ADM of Resident #2 ' s reclining wheelchair located in his office. The left arm rest which included the left side of the chair was missing. There was a gray metal arched structure noted on the left side of the chair which appeared much lower than the visible right armrest. On 08/12/15 at 3:13 p.m. an interview was conducted with S4LPN. She stated she recalled the incident that occurred on 07/06/15. She stated she was caring for Resident #2 prior to leaving for dialysis and when he returned from dialysis. She stated had a reclining wheelchair and he was a two person assist for transfers. She was asked if she documented when the resident left for dialysis. She stated she didn ' t document when the resident left for dialysis but did recall he left sometime before lunch. She explained on the day of the incident she was all the way in the back on her last med pass when she was told he was on the floor. She stated when she arrived in his room he was on the floor and his head was at the foot of the bed. She further explained he had a moderate amount of blood on the floor and blood to his left eye. She stated he also had a gash on his forehead. She stated he had no previous attempts to try to get out of his wheelchair and he was not the type of resident to fidget with his wheelchair. On 08/12/15 at 3:00 p.m. an interview was conducted with S11DR. He stated he drove Resident #2 to and from dialysis on 07/06/15. He stated when they returned to the facility after dialysis he rolled him back into his room and left him tilted in his wheelchair across from his bed. He stated he didn ' t recall if anything was wrong with the resident ' s wheelchair. He stated he wrote the time the resident returned to the facility in the transportation log. He stated he didn ' t remember telling any of the staff that the resident was back from dialysis. On 08/12/15 at 3:45 p.m. an interview was conducted with S6CNA. She stated she recalled the incident that occurred on 07/06/15. She stated S5CNA came to get her to help transfer. She stated we did not have to use a lift for him. She explained he was a two person assist. She stated when we walked in the room they both saw him on the floor. She stated he never tried to get out of bed that she knew of and never fidgeted with his wheelchair. She stated his wheelchair was reclined. On 08/13/15 at 8:51 a.m. an observation was made with S12HR of the facility video of Resident #2 on 07/06/15. She was asked if she had a video of the resident leaving the facility for dialysis in the morning on 07/06/15. She stated we can try to get that we only recorded the resident returning to the facility for the attorneys. An observation was made of the video stamped 3:13 p.m. revealed Resident #2 being rolled into the facility through the South Entrance (Ambulance Entrance) by S11DR in his reclining wheelchair with a surgical mask on his face with an orange blanket across his lap. His right arm was resting on the right arm rest. The left arm was much lower and no arm rest was visible. On 08/13/15 at 9:10 a.m. an observation was made of the facility video stamped 3:13 p.m. and another video stamped 3:20 p.m. with S1ADM and S2DON with S12HR present. S1ADM and S2DON both confirmed there was no left arm rest noted on Resident #2 ' s reclining wheelchair. After S2DON reviewed the facility videos on the morning of 07/06/15 she was able to obtain footage of Resident #2 leaving the facility with S11DR for dialysis. An observation was made of the video stamped 8:41 a.m. which revealed Resident #2 with the orange blanket across his lap. S1ADM and S2DON were asked to describe what they saw in the video. S1ADM stated it looked like the resident is resting his left arm on the humplike metal piece on the chair. He stated he did not see a left arm rest on the left side of the wheelchair. S2DON stated she agreed with S1ADM ' s observation of the video. On 08/13/15 at 10:27 a.m. an interview was conducted with S7CNA. She stated she was familiar with Resident#2. She stated after the incident that occurred on 07/06/15 there were in-services on lock out, tag out. She explained if equipment was broken the staff was to put a tag on the equipment then place the equipment in the designated room so maintenance could look at it. She stated the facility did not tell the staff to stay with the resident when the equipment was broken. On 08/13/15 at 10:34 a.m. an interview was conducted with S8CNA. She stated she was familiar with Resident #2 and was aware of the incident that occurred on 07/06/15. She stated the resident was on contact precautions, he required two person assist, incontinent care and needed assistance with feeding. She stated he didn ' t require any special equipment to move him. She stated he had a tilt wheelchair because of dialysis. She stated it was the first time she took care of the resident was sometime in the beginning of July, 2015. She stated remembered one of the arm rests was missing. She was asked if she reported the missing armrest to anyone. She stated she informed the nurse on duty that day. She stated the nurse told her to put him in it because he needed to got to dialysis and that was the only reclining wheelchair they had available. She stated after the incident that occurred on 07/06/15 she received in-services regarding tag out. She stated the staff was to put a tag on the broken equipment and take to maintenance. She stated she was not informed to stay with the resident if the equipment was broken. On 08/13/15 at 11:27 a.m. a telephone interview was conducted with S5CNA. She stated she recalled the incident that occurred on 07/06/15 involving Resident #2. She went in his room and he was in his wheelchair reclined back and brought him a gown. She stated she then went to the nursing station and to get another CNA to help get him into bed. She stated his wheelchair was by his bed. She stated she noticed one of his arm rests was off. She stated it was the second day she saw the wheelchair in his room but didn ' t recall if it was missing an arm rest prior to the incident. She stated after the incident she received in services regarding broken equipment. She stated broken equipment was to be tagged out. She stated she was not informed to stay with a resident with broken equipment. On 08/13/15 at 2:11 p.m. an interview was conducted with S2DON. She stated when Resident #2 came into the facility the family told her that at home he had a tendency to lean forward. She stated he came in on 06/30/15 (Tuesday) and on 07/01/15 (Wednesday) morning he needed to go to dialysis. She stated she instructed the CNAs to go get another patient ' s reclining chair. She explained the particular chair he fell out of was not the chair she informed the CNAs to go get. She stated she didn ' t know where the chair he fell out of came from. She stated she did not know that the arm was missing. She was asked what did the facility do after this incident occurred. She stated now we do lock out tag out. She explained any of the staff could tag it out. She stated the tags were located at the nursing station. She stated if the equipment was mobile then the staff was expected to take the equipment to maintenance room and document it in maintenance log. She stated maintenance was checking the equipment. She stated if there are any problems then they would alert her. She stated she gave them a census sheet and maintenance would give it back to her when they were done checking the equipment. She stated her QA was maintenance checks and ensuring no broken equipment. She hasn ' t had any since the incident occurred. She stated she has a safety round sheet she does quarterly she does random observations of safety. She did not re in-service on safety issues. On 08/13/15 at 2:52 p.m. an interview was conducted with S13MS. He was asked what was he responsibility regarding broken equipment. He stated we lock them out tag them out and put in supply room until repairs could be made. He explained the maintenance book was located at nursing station. He stated any staff member could document that in the book. He stated he checks equipment monthly. He stated he checked the lifts, and wheelchairs. He stated his last check was 08/01/15. He stated was given a list of names to check equipment. He stated after he checked it then he signed it and gave it to S2DON. He stated this process started it about 2 months ago. On 08/13/15 at 3:51 p.m. an interview was conducted with S2DON. She explained she gave maintenance a census list. She stated maintenance would write down any problems and give it back to her. She stated maintenance log was kept at the nursing station and monthly check lists were kept in her office. She was asked how did she ensure the staff retained information regarding the lock out/tag out policy and to stay with the resident when there was broken equipment she stated she had it on her to do list for September. On 08/13/15 at 4:44 p.m. an interview was conducted with S2DON. She demonstrated with Resident #2 ' s reclining wheelchair the position of the resident and wheelchair on 07/06/15. She stated the resident was found prone with his head noted at the foot of the bed and bleeding from the left side of his head. She stated the left side of the wheelchair was parallel to the bed and approximately 3 or 4 feet away from the bed. She stated the resident was found on left side of wheelchair. On 08/14/15 at 8:42 a.m. an interview was conducted with S2DON. She stated started in-servicing last night and again this morning to reiterate the lock out tag out policy and not to leave the resident unattended with faulty equipment. Resident #5 Review of the clinical record for Resident #5 revealed she was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Review of Resident #5 's most recent MDS (Minimum Data Sets) 3.0 dated 07/08/15 revealed the Resident was assessed a BIMS (Basic Interview of Mental Status) score of 1-Severely Impaired. The Resident's functional status was documented to have required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. Resident #5 was assessed as totally dependent on staff for bathing. She was assessed to have required limited assistance with transfers and locomotion on unit. The Resident was assessed to have been always incontinent of bowels and bladder. Resident #5 was not assessed to have been on a toileting program. Review of the Resident's Care Plan revealed the following regarding falls: Problem dated 07/02/15- At risk for falls. 07/03/15-Slid out of W/C (wheelchair). No injury noted. Approaches- 07/03/15-OT (Occupational Therapy) to evaluate and treat as indicated. 08/07/15-fell during unassisted transfer (no injury noted). Approaches-Continues with OT, keep door open for frequent visual checks 08/09/15-Found sitting on floor in her room, states she was trying to go to the toilet (No injury Noted) Approaches-Toileting every 2 hours, observe for S/S of need to toilet (anxious, fidgety, verbal C/O (complaints), assist as needed) (Review of the Care Plan revealed the Resident was admitted on incontinent Care Q2H(every 2 hours) 08/10/15-Attempted unassisted transfer forgot to lock W/C (Wheelchair) fell to floor (no injury noted)- Approaches -08/10/15-Therapy working on trial with Merry Walker 08/11/15-fell while attempting unassisted transfer, hematoma to forehead noted. Approaches-08/11/15-Chair Alarm to W/C order rollback brakes for W/C. Resident unsafe with Merry Walker without 1:1 assist/Supervision. Review of the Multidisciplinary Screening Form dated 07/03/15 revealed the following: The Resident was assessed to exhibit deficit or change in one or more of the following areas: Muscle Weakness, Trunk Flexibility, Balance Disturbance, Abnormal Posture/standing/sitting, bed mobility, Transfers, Gait Disturbance, Pain with Movement, Coordination and Dexterity, Difficulty with Grooming/Dressing/Toileting and Difficulty with Transfers. The Resident was recommended for therapy evaluations as follows: PT (Physical Therapy)-Patient/Caregiver/family education with safety awareness with locking brakes on wheelchair for all transfers-Pt. New admit. OT (Occupational Therapy)-Used Rolling Walker at home prior to admit and hand held on furniture. Patient would benefit from PT/OT treatment for [REDACTED]. ST (Speech Therapy)-No significant change in communication or swallowing per family. (No evaluation recommended) Review of physician's orders [REDACTED]. 07/06/15- OT evaluation and treatment 3 X wk. X 8 wks. (3 times a week for 8 weeks) for treatment lack of coordination. 07/07/15- PT Services-PT evaluation and Tx. (Treatment) 3 X wk. X 8 wks. for HTN and OA(Osteoarthritis) and Tx./ Dx.(Treatment/Diagnosis)-[DIAGNOSES REDACTED]. An observation of Resident #5 was conducted at 10:59 a.m. on 08/12/15. The Resident was observed sitting in a wheelchair in therapy. Resident #5 's wheelchair was observed to be in good repair with no missing parts. The Resident was observed to have been neatly dressed and groomed with proper fitting shoes and socks. There was observed bluish bruising to her face in the area of her eyes bilaterally. She was appropriately responsive in verbal conversation. She was able to talk about a recent fall and reported that she hurt her head and face. An interview was conducted with S10OT on 08/12/15 at 11:00 a.m. She stated that Resident #5 was presently receiving therapy with PT and OT. She stated the staff was working with the Resident to improve balance, safety, ADLs (Activities of Daily Living), dressing, toileting, ambulation and gait. The Therapist reported Resident #5 had memory problems which hampered her wheelchair safety-locking and remembering wheelchair safety. The Occupational Therapist stated the staff had begun training with Resident #5 with the Merry Walker. S10OT stated that this device trial allowed seating and walking and did not require her to remember wheelchair safety. The Therapist reported that Resident #5 did well with the walker with going straight but was unsteady with any turns. She said the Resident had received therapy several weeks before any falls and she anticipated Resident #5 would require another 5-6 weeks of therapy. An interview was conducted with S7CNA on at0 8/12/15 12:19 p.m. She verified that she worked with Resident #5. She stated the Resident required assistance with ADLs and was a high risk for falls. She said that interventions in place were low bed, bed and chair alarm. The CNA reported the Resident was often up and had fallen by the time the alarm went off. The S7CNA said interventions were posted on the inside of the resident 's closet doors in each resident 's room. An observation of Resident #5 was conducted on 08/13/15 at 9:20 a.m The Resident was observed sitting in a chair directly on the right side of her wheelchair. It was observed that the Resident had a chair alarm connected at one end to her clothing and the other end of the alarm was connected to the wheelchair. The alarm was intact and not alarming. An interview was conducted with S3LPN on 08/13/15 at 9:25 a.m. She stated Resident #5 had fallen several times recently. She stated that all falls were documented in the chart. She stated that the Resident did not have a bed or chair alarm at that time. The Nurse verified the Resident was sitting in the chair beside her wheelchair and the chair alarm was intact and not alarming. When asked what she would do to prevent the Resident from getting up without assistance she stated that she would change the alarm to another alarm that was positioned in the seat of the wheelchair. She stated she was not aware that the Resident had a fall yesterday (08/11/15). Review of the Fall Risk Assessment revealed the following: 070/2/15-Resident assessed a Fall Assessment score of 10 07/10/15- Resident assessed a Fall Assessment score of 13 08/07/15- Resident assessed a Fall Assessment score of 13 08/09/15- Resident assessed a Fall Assessment score of 15 If the total score is 10 or greater the resident should be assessed at High Risk for potential falls. Review of the facility's Incident and Accident Reporting Forms for Resident #5 revealed the following: Date of Incident-07/03/15 Location-North Hall Day Room Was a restraint in use? No Description of incident- Resident sitting in W/C in Day Room leaning over to talk and pat on another resident. Then she slid out of wheelchair landing on buttocks. No injuries noted. Denies any pain. Did not hit head . Time-9:40 a.m. VS-BP-162/78, P-74, RR-20 T-98.3 Fall History: One fall isolated event. Diagnosis/Conditions-Seizure Disorder, Cognitively Impaired Description of fall- Slid out of W/C while leaning over to talk and pat on another resident . Type of injury-None Description of Injury-None Functional assessment-The Resident was assessed to have required partial assistance with dressing, wheelchair Management, toileting, transferring, rising/ standing and ambulation. Interventions- Faxed MD (Medical Doctor) for order for a W/C alarm . Date of Incident-08/07/15 Location-Resident ' s Room Was a restraint in use? No Description of incident- According to family visited roommate who witnessed fall . Time-5:35 p.m. VS-BP-110/88, P-69, RR-18, T-98 Fall History: Fall within 6 months Diagnosis/Conditions-Unsteady Gait, Seizure Disorder, Cognitively Impaired Description of fall- Family member for roommate witnessed fall. Resident was discovered sitting on buttocks on floor with back against foot of her bed. No injuries noted, did not hit head, only fell to her buttocks . Description of Injury-None seen. Functional assessment-Partial assistance needed with dressing, toileting, transfers, rising/ standing and ambulation. Interventions-Chair Alarm. Date of Incident-08/09/15 Location-Resident ' s Room Was a restraint in use?-No Description of incident- Unwitnessed. Unknown exactly what occurred. Unreliable account. Resident stated that she was going to the restroom and fell to the floor . Time-10:25 a.m. VS-BP-128/87, P-64, RR-20, T-97.8 Fall History: Similar pattern to previous falls Diagnosis/Conditions- Unsteady Gait, Seizure Disorder, Cognitively Impaired Description of Injury-None apparent Functional assessment- Partial assistance needed with dressing, toileting, transfers, rising/ standing and ambulation. Interventions- Spoke with Resident about always calling for help after ge

Based on interviews and record reviews the facility failed to immediately consult with 1 (Resident #4) of 5 (#1, #2, #3, #4, #5) resident's physician when an accident involving the resident resulted in a significant injury, required physician intervention, and a need to alter treatment significantly by failing to: 1) follow through on a facsimile sent to the physician regarding resident #4's injury, and 2) inquire if resident #4's physician responded the following day. Resident #4 was admitted to the facility on [DATE] for rehabilitation following hip surgery after falling at home. Upon admission to the facility, she required two persons to transfer and was transferred by one Certified Nursing Assistant on 11/23/12. Resident #4 sustained a right tibia fracture at approximately 2:00 p.m. on Friday, 11/23/12 and was not transferred to a local hospital emergency room until Saturday 11/24/12 at 10:55 a.m. Findings: On 12/18/12 at 8:45 a.m. an interview was conducted with S7LPN. She verified she was the Wound Care Nurse. She was asked what happened to resident #4 on 11/23/12. She stated S3Sitter came and got her and asked her to look at resident #4's leg. She stated, "I noticed it was red and and a little swollen". She stated, "Just to be safe I sent a fax to (name of a physician) who was on call for (name of resident #4's attending physician) between 3:30 p.m. - 4:00 p.m. and informed him of what I observed". She stated following this she was getting ready to leave work and returned on Monday, 11/26/12. She was asked if she reported this to anyone. She stated she reported this to S8LPN who was working 6 a.m. - 6 p.m. on 11/23/12. She was asked if she received a response from the facsimile she sent to the physician. She verified she did not receive a response. S7LPN stated, "Had I known the situation that the leg was broken, I would have sent her to the hospital". She was asked if she called the physician's office to see if the facsimile was received. She stated no. S7LPN was asked to review the document entitled, "I&A Reporting Form" dated 11/23/12 when she was called to resident #4's room by the sitter to observe resident #4's leg. She confirmed the I&A Reporting Form documented (name of physician) was notified at 3:30 p.m.. S7LPN was asked if this was by facsimile. She verified it was. On 12/18/12 at 9:15 a.m. an interview was conducted with S8LPN. She verified she was working the 6 a.m. - 6 p.m. shift on Friday, 11/23/12. She verified S7LPN sent a facsimile to (name of physician). She verified she was responsible to follow up on the facsimile. She verified she did not hear anything from the physician prior to leaving this shift. She was asked if she worked the following day, Saturday, 11/24/12. She verified she did. She stated she returned on Saturday, 11/24/12 for the 6 a.m. - 6 p.m. shift and did not receive a report from the night nurse she relieved. She stated this nurse was no longer employed at the facility. S8LPN was asked to review her Nurses Notes on 11/24/12. S8LPN confirmed her first entry in the Nurses Notes regarding resident #4's leg was at 10:00 a.m. She stated it appeared swollen & bruised. S8LPN stated she reported her observations of resident #4's leg to S17RN at 10:00 a.m. who was the Charge Nurse that weekend. She was asked if there was a response from the facsimile sent to the physician on 11/23/12. S8LPN stated, "Nobody knew if there was a response from the physician". She was asked if she was aware of the facsimile sent on Friday. She stated yes. She was asked if she was the nurse caring for resident #4 since the injury to resident #4's tibia on 11/23/12. She stated yes. She stated she started working at the facility in October 2012. She verified resident #4 was admitted with a right [MEDICAL CONDITION] and was at the facility for rehabilitation. She stated she remembered this resident was improving with therapy and would be up in her wheelchair or recliner. When asked if this resident had declined since admission she stated, "Yes, she is now bedbound and experienced a decline since this injury". On 12/18/12 at 10:10 a.m. an interview was conducted with S2ADON. She was asked to review the Nurses' Notes documented by S9LPN dated 11/23/12 the evening after resident #4 sustained the injury to her right lower leg. Review of this Nurses' Notes revealed the following: "11/23/12 9:30 p.m. Pt (Patient) lying in bed in bed in supine position AAOX3 (Awake, Alert, Oriented X three) no c/o (complaints), no s/s (signs and symptoms) of pain or discomfort, tolerated meds well, will continue to monitor". S2ADON stated, "Resident #4 was not in pain according to the documentation from this nurse". She was asked if there was any evidence S9LPN assessed resident #4's right lower leg. S2ADON verified there was no documented evidence contained in the Nurses Notes confirming a visual assessment of resident #4's lower right leg was performed by S9LPN. Review of the Nurses Notes dated 11/24/12 at 9:30 a.m. for resident #4, the following day after resident #4 was transferred by one CNA (S15CNA) and sustained a right tibial fracture, revealed in part the following: .... "is complaining of some discomfort in Right ankle. Family members present in room- asked if MD would be coming by to look at resident's Right foot and leg. Assessment revealed some moderate swelling and cellular puffiness in right ankle and foot accompanied by some red-bluish discoloration. Resident does have a significant skin tear several inches above the foot on the mid-lateral aspect of the right leg".... Pedal pulses are faint and fade to count on palpitation.... (Name of physician) called and given report of observations with order to send to (Initials of hospital) ER for evaluation, x-ray, and treatment if necessary". Resident #4 sustained the right tibia fracture at approximately 2:00 p.m. on Friday, 11/23/12 and was not transferred to a local hospital ER until Saturday 11/24/12 at 10:55 a.m.

Based on interviews and record reviews the facility failed to provide services by qualified persons in accordance with 4 (#1, #2, #3, #4) of 5 (#1, #2, #3, #4, #5) residents' written plan of care by failing to 1) provide the necessary transfer assistance for resident #4 who required two person assist; 2) use a two person assist and Total Lift device for Resident #1 3) use a two person assist for Resident #2 4) use a Total Lift Device for Resident #2. Resident #4 was admitted to the facility on [DATE] for rehabilitation following hip surgery after falling at home. Based on the initial comprehensive assessment and written plan of care upon admission to the facility, resident #4 required two persons to transfer. On 11/23/12 resident #4 experienced harm when she was transferred by one CNA (Certified Nursing Assistant) and sustained a right tibial fracture. Findings: On 12/17/12 a record review was conducted for resident #4. She was admitted to the facility on [DATE]. Review of the History and Physical prior to admission to the facility dated 09/16/12 revealed she was [AGE] years old and lived alone at home. Documentation revealed, "According to the family, she has mild dementia but typically ambulates in her house alone with a walker". Further review of the History and Physical revealed she was found at home, alert and oriented, lying on her right hip and complained of right hip pain. She was taken to a local emergency room and was found to have a right intertrochanteric [MEDICAL CONDITION]. Resident #4 was transferred to another hospital and underwent an Open Reduction Internal Fixation (ORIF) surgical procedure for her right [MEDICAL CONDITION]. Review of the History and Physical dated 09/24/12 dictated by resident #4's nursing home attending physician revealed in part the following: "..... she was stable and transferred to the nursing home for rehabilitation". Review of the Care Plan revealed in part the following problem identified for resident #4 upon admission: Problem Onset: 09/21/12 Requires Assistance With ADLs Approaches included: Max assist with transfers. Further review of the C.N.A. (Certified Nursing Assistant) ADL (Activities of Daily Living) Plan of Care dated 10/18/12 revealed in part the following: "Transfer Skills Two Person Assist". On 12/17/12 at 9:30 a.m. an observation and interview was conducted with resident #4 and S3Sitter in resident #4's room. S3Sitter verified she was resident #4's sitter. She stated she had known this resident a long time. She stated this resident was her 2nd grade teacher. Resident #4 acknowledged she was a school teacher. S3Sitter was asked why this resident was admitted to the nursing home. She stated she fell at home and broke her hip. She stated she was receiving therapy at the nursing home and was doing much better until her right leg was broken. When asked what happened to her right leg she stated, "A new CNA was transferring her from the wheelchair to the bed and didn't transfer her correctly". S3Sitter stated, (resident #4) will stiffen up when you try to stand her. She stated this CNA had resident #4 close to the bed and hit her right leg on the bed and broke it. She stated resident #4 told the CNA, "You hurt me". S3Sitter stated, "This CNA transferred resident #4 by herself". She stated she did not know why this CNA transferred her by herself because resident #4 required two persons to transfer. She stated she noticed something was wrong after this CNA transferred resident #4. S3Sitter stated resident #4's right lower leg became warm and swollen and started to complain of pain on Friday, 11/23/12. S3Sitter was asked if she remembered the name of the CNA who transferred resident #3 and broke her leg. She stated she did not remember her name. She was asked if she witnessed the CNA transferring resident #4. She verified she did. Review of a document entitled, "Louisiana DHH (Department of Health and Hospitals) Client Incident Report" Incident ID: revealed in part the following documented evidence: Victims (Resident #4) Case Notes Description: "Resident right lower leg noted to be warm, slightly [MEDICAL CONDITION] on Friday evening, 11/23/2012. Attempted to contact physician for orders, no response received. On Saturday, 11/24/2012, nurse noted that right lower leg was grossly [MEDICAL CONDITION] and discolored. Contacted physician and new order received to send to ER (emergency room ) for eval (evaluation). 3:30 pm resident returns to facility with [DIAGNOSES REDACTED].. Currently under care of PT/OT services for status [REDACTED]. Attached to the Client Incident Report revealed a written statement from S3Sitter documenting the following: "At 2:15 p.m. Friday, Nov. 23, CNA came in to transfer (resident #4) from wheelchair to bed. She was by herself... (Resident #4) right leg did not turn because she was stiff. (Resident #4) yelled you hurt me". On 12/17/12 at 3:10 p.m. an interview was conducted with S5CNASup. She was asked if she was aware of the incident that occurred on 11/23/12 when resident #4's right tibia was fractured. She stated, "I think it happened over a weekend and I was not here". She stated when she came back on Monday she was told by the nurse or Director of Nurses that her leg was broken during a transfer. She stated S15CNA transferred resident #4 by herself and lied about it. She stated the facility disciplined this CNA and she was fired for lying. S5CNASup. was asked to review the C.N.A. ADL Plan of Care dated 10/18/12. S5CNASup. confirmed resident #4 required two persons for transfers. On 12/18/12 at 10:10 a.m. an interview was conducted with S2ADON. She was asked to review the employee record of S15CNA. She verified S15CNA was the CNA who was accused of transferring resident #4 by herself on 11/23/12. She reviewed S15CNA's employee file and confirmed this record contained documented evidence of a Nursing Assistant Competency Check List for transfers completed on 11/01/12. She was asked if S15CNA was able to demonstrate competency as identified in resident #4's assessments and plan of care. S2ADON stated "This CNA made a bad decision not to follow the resident's plan of care and transfer her with 2 person assist. Findings: Resident #1 Review of the clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/17/12 at 11:55 a.m. the resident was observed sitting up in bed eating her lunch. She was asked how long had she been a resident at the facility. The resident stated "I'm not sure". She was asked how many staff assist her to get in and out of bed. The resident stated "one". Review of the Certified Nursing Assistant/ Activities of Daily Living Care Plan (CNA/ADL), posted inside the resident's closet door revealed the following transfer instructions: Two person assist, use total lift. High risks for falls. Review of the Minimum Data Set (MDS) Assessments, with Assessment Reference Dates (ARD) of 08/26/12 and 11/21/12, Section G, revealed the following: 08/26/12: Section G: Functional Status: Transfer: Support Provided: Two persons physical assist. Balance: moving from seated to standing: not steady, only able to stabilize with staff assistance; walking: activity did not occur; turning around: activity did not occur; moving on and off toilet: not steady, only able to stabilize with staff assistance; surface to surface transfer: not steady, only able to stabilize with staff assistance. 11/21/12: Section G: Functional Status: Transfer: Support Provided: Two persons physical assist. Balance: moving from seated to standing: not steady, only able to stabilize with staff assistance; walking: activity did not occur; turning around: activity did not occur; moving on and off toilet: not steady, only able to stabilize with staff assistance; surface to surface transfer: not steady, only able to stabilize with staff assistance. Review of the resident's care plan revealed the following: #1 Problem Onset: 10/19/09 Risk for Falls, Right Sided [MEDICAL CONDITION]. Goal & Target Date: Will have no injury related to falls during next 90 days: 06/08/12, 08/12/12, 11/12/12, 2/13/12. Approaches: Extensive assist needed for transfers and toileting with two staff. 03/04/12 eased to floor per CNA after becoming weak. 03/04/12 Reinforced staff 2 person assist with transfers sit to stand lift... 09/07/12 Slipped from side of bed. 09/07/12 CNA Counciled to always use a 2 person assist... #2 Problem Onset: 02/01/12 Potential for Injury Goal & Target Date: Will have no Injury Related to [MEDICAL CONDITION] Especially Fracture during next 90 days. 06/08/12; 08/12/12, 11/12/12, 02/13/12 Approaches: Staff Assist times two, with lift all transfers ... Review of the Fall Risk Assessments done on 10/20/12 and 11/21/12, revealed the resident scored 14, indicating she was " High risks for Falls " . Review of the facility's Incident & Accident Reporting Form, dated 09/07/12, revealed in part, the following: 4:00 p.m. S13CNA was attempting to transfer resident from wheelchair to bed. Resident began to slip away from the CNA. S13CNA gently assisted resident to the floor. CNA received assistance transferring resident from the floor to the bed ..... No injuries noted.... Review of S13CNA's statement revealed in part, the following: When I was putting ______ in the bed I set her up on the side of bed and then she started to slip down on the floor so I laid her down on the floor and then I went in the hallway and I saw _____, CNA and I asked her to come and help me get _____ up from the floor and than once we got her up I went to tell the nurse what happened. Review of the facility's Fall Evaluation form revealed in part, the following: 09/07/12 4:00 p.m. Day of Week: Friday 2. Risk Factors: receives more than 5 medications, cardiovascular medications, diuretics. 3. Risk Factors: [MEDICAL CONDITIONS] Disorder, Diabetes, Vision Deficit, [MEDICAL CONDITION]. 4. Description of Fall: From wheelchair to bed. 11. Nurse's Account: S13CNA was transferring resident from wheelchair to bed and the resident began slipping away from CNA. CNA assisted resident to floor gently. CNA received assistance to transfer resident from floor to bed. On 12/18/12 at 2:00 p.m. an interview was conducted with S6LPN. After reviewing the incident & accident form dated 09/07/12, she verified S13CNA transferred the resident without assistance and without using the total lift. On 12/18/12 at 2:30 p.m. an interview was conducted with S2ADON. After reviewing the incident & accident form dated 09/07/12, she verified S13CNA transferred the resident without assistance and without using the total lift. On 12/18/12 at 12:40 pm an observation was made of S11CNA and S12CNA in the Hall "a" bathroom as they assisted Resident #1 to change her brief. The CNAs used a sit to stand lift to transfer the client from her wheelchair. On 12/18/12 at 10:40 am an interview was conducted with S5CNASup. She was asked to review the CNA/ADL/ care plan posted on the inside of Resident #1's closet door. She was asked if this was the current care plan that the CNAs are to follow when providing care to the resident. S5CNASup stated "yes". She was asked if the resident required a two person assist for all transfers. S5CNASup stated "yes". She was asked if Resident #1 required the use of any sort of lift device. She stated " yes, we use the total lift on her ". S5CNASup further explained the total lift was a Hoyer lift with the "bed pad" used to transfer the resident. She was asked if the CNAs are ever to transfer this resident with the sit to stand lift device. She stated "no". On 12/18/12 at 2:00 p.m. an interview was conducted with S6LPN. She was asked to review Resident #1's CNA/ADL/ care plan and nursing care plan. She was asked if the resident required two persons assist for all transfers. S6LPN stated "yes". She was asked what type of lift device was required to transfer the resident. S6LPN stated "the total lift". She was asked if Resident #1 was an appropriate candidate for the sit to stand lift. S6LPN stated "no". On 12/18/12 at 2:30 p.m. an interview was conducted with S2ADON. She was asked to review Resident #1's CNA/ADL/ care plan and the nursing care plan. She was asked if the resident required two persons assist for all transfers. S2ADON stated "yes". She was asked what type of lift device was required to transfer the resident. S2ADON stated "the total lift". She was asked if Resident #1 was an appropriate candidate for the sit to stand lift. S2ADON stated "no". Resident #2 Review of the clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/18/12 at 8:45 a.m. an interview was conducted with the resident. She was asked how many staff assist her to get in and out of the bed. She stated "It takes two of them". The resident was asked if the staff ever use any type of equipment to get her out of the bed. She stated "they use that stand up thing". She went on further to state "when they use that stand up thing it only takes one person". Review of the Certified Nursing Assistant/ Activities of Daily Living Care Plan (CNA/ADL), posted inside the resident's closet door revealed the following transfer instructions: Two person assist. Review of the Minimum Data Set (MDS) Assessments, with Assessment Reference Dates (ARD) of 10/17/12; 11/19/12 and 11/25/12, Section G, revealed the following: 10/27/12: Section G: Functional Status: Section G: Functional Status: Transfer: Support Provided: Two persons physical assist. Balance: moving from seated to standing: not steady, only able to stabilize with staff assistance; walking: activity did not occur; turning around: activity did not occur; moving on and off toilet: not steady, only able to stabilize with staff assistance; surface to surface transfer: not steady, only able to stabilize with staff assistance. 11/19/12: Section G: Functional Status: Transfer: Support Provided: Two persons physical assist. Balance: moving from seated to standing: not steady, only able to stabilize with staff assistance; walking: activity did not occur; turning around: activity did not occur; moving on and off toilet: not steady, only able to stabilize with staff assistance; surface to surface transfer: not steady, only able to stabilize with staff assistance. 11/25/12: Section G: Functional Status: Transfer: Support Provided: Two persons physical assist. Balance: moving from seated to standing: not steady, only able to stabilize with staff assistance; walking: activity did not occur; turning around: activity did not occur; moving on and off toilet: not steady, only able to stabilize with staff assistance; surface to surface transfer: not steady, only able to stabilize with staff assistance. Review of the resident's care plan revealed the following: #1 Problem Onset: 09/28/12 Requires Assistance with ADLs ... Goal & Target Date: Will have needs/wants met through next 90 days. 12/28/12 Approaches: Requires extensive 2 person assist with transfers ...total dependence with two person assist for transfers. #2 Problem Onset: 09/28/12 Risks for Falls related to personal history of falls, chair bound, decreased muscular coordination ... Goal & Target Date: Will have no injury from falls through the next 90 days (12/28/12) Approaches: Assess Resident after each fall for causes and interventions ... Problem Onset: 10/19/12 Resident to floor by CNA Approaches: Transfer X 2 person assist Review of the resident's Fall Risk Assessments revealed the following: 09/25/12: Score 14/High Risk; 10/10/12: Score 14/High Risk; 10/19/12: Score 12/High Risk; 11/13/12: Score 14/High Risk. On 12/18/12 at 12:40 p.m. interview conducted with S11CNA and S12CNA, who were working on Hall "a" where Resident #2 resides. They were asked what was the procedure for transferring Resident #2. Both S11CNA and S12CNA stated the resident was a 2 person assist with the sit to stand lift. On 12/18/12 at 10:40 a.m. an interview was conducted with S5CNASup. She was asked to review the CNA/ADL/ care plan posted on the inside of the resident's door. She was asked if this was the current care plan that the CNAs are to follow when providing care to Resident #2. She stated "yes". She was asked if staff were to use any sort of lift device to transfer the resident. She stated "no". On 12/18/12 at 2:00 p.m. an interview was conducted with S6LPN. She was asked to review Resident #2's CNA/ADL/ care plan and the nursing care plan. She was asked if the staff were to use any sort of lift device to transfer the resident. She stated "no". On 12/18/12 at 2:30 p.m. an interview was conducted with S2ADON. She was asked to review Resident #2's CNA/ADL/ care plan and the nursing care plan. She was asked if the staff were to use any sort of lift device to transfer the resident. She stated "no". Resident #3 Review of the clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/17/12 at 12:30 p.m. the resident was observed sitting in a specialized supportive wheelchair with a self release seat belt, in the Hall "b" day area. The resident was awake but did not respond verbally when asked questions. Review of the CNA/ADL care plan posted inside the resident's closet door revealed the following transfer instructions: Two Person Assist, Use Total Lift. Review of the Minimum Data Sets with Assessment reference Dates of 05/22/12; 10/22/12 and 11/11/12 revealed the following: 10/20/12: Section G: Section G: Functional Status: Transfer: Support Provided: Two persons physical assist. Balance: Moving from seated to standing, walking, turning around, moving on and off toilet, surface to surface transfer: activity did not occur. 11/11/12: Section G: Functional Status: Transfer: Support Provided: Two persons physical assist. Balance: Moving from seated to standing, walking, turning around, moving on and off toilet, surface to surface transfer: activity did not occur. 11/11/12: Section M: Skin Conditions: G. Skin Tears (checked). Review of the resident's care plan revealed the following: #1. Problem Onset: 07/07/10: Potential for impaired skin integrity, incontinent of B&B. Goal & Target dates: Will maintain optimal integrity over the next 90 days. Approaches: Handle with care; 2 staff for bed mobility; cushion in wheelchair #2. Problem Onset: 10/28/12 Skin tear to top of (L) hand Goal: will show signs of improvement within the next 90 days. Approach: Medical Doctor notified, clean with normal saline solution, pat dry, cover with dry dressing to be changed daily. Review of the facility's Incident & Accident Reporting Form, dated 10/28/12, revealed the following: Resident was being transferred from a special supportive wheelchair back to bed by 2 attendants when the attendants laid her down they noticed bright red bleeding from the top of (L) hand. Assessment shows a fresh skin tear 5.5 cm long straight line tear with edges intact top of (L) hand. Resident must have bumped hand against turned up side rail in the transfer. 1st aid given with cleansing normal saline-pat dry-applying 10 micro steri-strips to hold edges together until adherence. Dry bandage applied and covered, daily observation to be done. Review of the facility's Accident/Incident/injury Investigation form revealed the following: CNAs were transferring resident back to bed from special supportive wheelchair when after they got resident into bed,they observed fresh bleeding on top (L) hand-called nurse____ to come assess and treat. Interventions to help prevent possibility of reoccurrence: Take more caution when transferring residents-more time to size up and position self and the resident before actual transfer. Review of the resident's Fall Risks Assessments revealed the following: 05/22/12 Score 14/High Risk; 05/30/12 Score 14/High Risk; 08/10/12 Score 14/High Risk; 08/22/12 Score 10/High Risk; 08/28/12 Score 14/High Risk; 09/04/12 Score 14/High Risk; 09/19/12 Score 15/High Risk On 12/18/12 at 10:40 a.m. an interview was conducted with S5CNASup. She was asked to review the CNA/ADL/ care plan posted on the inside of the resident's closet door. She was asked if this was the current care plan that the CNAs are to follow. She stated"yes". She was asked if the resident required a two person assist for all transfers. She stated "yes". She was asked if Resident #3 required the use of any sort of lift device. S5CNASup stated 'yes, we use the total lift on her". She was asked if the CNAs are ever to transfer this resident from bed to chair and back without the use of the total lift. S5CNASup stated "no'. On 12/18/12 at 2:00 p.m. an interview was conducted with S6LPN. She was asked to review Resident #3's CNA/ADL/ care plan and the nursing care plan. She was asked if the staff were to ever transfer the resident without the use of the total lift. She stated "no". On 12/18/12 at 2:30 p.m. an interview was conducted with S2ADON. She was asked to review Resident #3's CNA/ADL/ care plan and the nursing care plan. She was asked if the staff were to ever transfer the resident without the use of the total lift device. She stated "no". On 12/18/12 at 11:40 a.m. an interview was conducted with S10CNA, working on Hall "b", where Resident #3 resided. She verified she and S14CNA transferred the resident from her wheelchair to her bed on 10/28/12. She was asked how was Resident #3 to be transferred. S10CNA stated "with 2 people". She was asked if the resident required a lift device. S10CNA stated "no". She was asked if the a lift device was used on 10/28/12 when she and S14CNA transferred the resident from her wheelchair to her bed. She stated "no". She was asked how did she think the resident got the skin tear. She stated " I'm not sure cause I didn't see it happen but it might have bumped the bed rail.

Based on interviews and record reviews the facility failed to ensure that a nurse aide was able to demonstrate competency in skills and techniques necessary to care for 4 ( #1, #2, #3, #4) of 5 (#1, #2, #3, #4, #5) residents' needs, as identified through the residents' assessments and described in their plans of care by failing to: 1) ensure the Certified Nursing Assistant (CNA) followed the plan of care for resident #4; 2) conduct an investigation after resident #4 received skin tears and determine the causes of the skin tears; 3) use the correct mode of transfer for residents #1, #2 and #3; and 4) use the correct procedure to secure the standing sling on the Sit to Stand device for resident #1. Resident #4 was admitted to the facility on [DATE] for rehabilitation following hip surgery after falling at home. Upon admission to the facility, she required two persons to transfer and was transferred by one CNA on 11/23/12. Resident #4 experienced harm on 11/23/12, was transferred to a local hospital emergency room the following day, and was found to have sustained a right tibial fracture when she was transferred by one CNA. Findings: On 12/17/12 a record review was conducted for resident #4. She was admitted to the facility on [DATE]. Review of the History and Physical prior to admission to the facility dated 09/16/12 revealed she was [AGE] years old and lived alone at home. Documentation revealed, "According to the family, she has mild dementia but typically ambulates in her house alone with a walker". Further review of the History and Physical revealed she was found at home, alert and oriented, lying on her right hip and complained of right hip pain. She was taken to a local emergency room and was found to have a right intertrochanteric [MEDICAL CONDITION]. Resident #4 was transferred to another hospital and underwent an Open Reduction Internal Fixation (ORIF) surgical procedure for her right [MEDICAL CONDITION]. Review of the History and Physical dated 09/24/12 dictated by resident #4's nursing home attending physician revealed in part the following: "..... she was stable and transferred to the nursing home for rehabilitation". Review of the document entitled, "Minimum Data Set (MDS) - Version 3.0 For Nursing Home Resident Assessment and Care Screening" Assessment Reference Date (ARD): 09/28/12 (7 days following admission to the facility) revealed in part the following: Section G - Functional Status Transfer: self-performance was coded 4. Total dependence - full staff performance every time during entire 7-day period. Transfer: support provided was coded 3. "Two+ persons physical assist". Review of the Care Plan revealed in part the following problem identified for resident #4 upon admission: 1) Problem Onset: 09/21/12 Requires Assistance With ADLs Approaches included: PT (Physical Therapy) / OT(Occupational Therapy) / ST(Speech Therapy) to eval (evaluate) and treat pt (patient) as indicated. Max (Maximum) assist with transfers. Further review of the C.N.A. (Certified Nursing Assistant) ADL (Activities of Daily Living) Plan of Care for resident #4 dated 10/18/12 revealed in part the following: Transfer Skills Two Person Assist. On 12/17/12 at 9:30 a.m. an observation and interview was conducted with resident #4 and S3Sitter in resident #4's room. S3Sitter verified she was resident #4's sitter. She stated she had known this resident a long time. She stated this resident was her 2nd grade teacher. Resident #4 stated and verified she was a school teacher. S3Sitter was asked why this resident was admitted to the nursing home. She stated she fell at home and broke her hip. She stated she was receiving therapy at the nursing home and was doing much better until her right leg was broken. When asked what happened to her right leg she stated, "A new CNA was transferring her from the wheelchair to the bed and didn't transfer her correctly". S3Sitter stated, (resident #4) will stiffen up when you try to stand her. She stated this CNA had resident #4 close to the bed and hit her right leg on the bed and broke it. She stated resident #4 told the CNA, "You hurt me". S3Sitter stated, "This CNA transferred resident #4 by herself". She stated she did not know why this CNA transferred her by herself because resident #4 required two persons to transfer. S3Sitter stated resident #4's skin was like, "onion skin, very thin". She stated she noticed something was wrong after this CNA transferred resident #4. S3Sitter stated resident #4's right lower leg became warm and swollen and started to complain of pain on Friday, 11/23/12. S3Sitter was asked if she remembered the name of the CNA who transferred resident #3 and broke her leg. She stated she did not remember her name. She was asked if she witnessed the CNA transferring resident #4. She verified she did. Review of a document entitled, "Louisiana DHH (Department of Health and Hospitals Client Incident Report" Incident ID: revealed in part the following documented evidence: Victims (Resident #4) Case Notes Description: "Resident right lower leg noted to be warm, slightly [MEDICAL CONDITION] on Friday evening, 11/23/2012. Attempted to contact physician for orders, no response received. On Saturday, 11/24/2012, nurse noted that right lower leg was grossly [MEDICAL CONDITION] and discolored. Contacted physician and new order received to send to ER (emergency room ) for eval (evaluation). 3:30 pm resident returns to facility with [DIAGNOSES REDACTED].. Currently under care of PT/OT services for status [REDACTED]. Attached to the Client Incident Report revealed a written statement from S3 documenting the following: "At 2:15 p.m. Friday, Nov. 23, CNA came in to transfer (resident #4) from wheelchair to bed. She was by herself... (Resident #4) right leg did not turn because she was stiff. (Resident #4) yelled you hurt me". The facility conducted and investigation following this incident and confirmed the finding "Neglect: Caregiver" to be substantiated. On 12/17/12 at 3:10 p.m. an interview was conducted with S5CNASup. She was asked if she was aware of the incident that occurred on 11/23/12 when resident #4's right tibia was fractured. She stated, "I think it happened over a weekend and I was not here". She stated when she came back on Monday she was told by the nurse or Director of Nurses that her leg got broken during a transfer. She stated a S15CNA transferred resident #4 by herself and lied about it. She stated the facility disciplined this CNA and she got fired for lying. S5CNASup. was asked to review the C.N.A. ADL Plan of Care dated 10/18/12. S5CNASup. confirmed resident #4 required two persons for transfers. On 12/18/12 at 10:00 a.m. S2ADON was asked to review the employee record of S15CNA. She verified S15CNA was accused of transferring resident #4 by herself on 11/23/12. She reviewed S15CNA's employee file and confirmed this record contained documented evidence of a Nursing Assistant Competency Check List for transfers completed on 11/01/12. She was asked if S15CNA was able to demonstrate competency as identified in resident #4's assessments and plan of care. S2ADON stated "This CNA made a bad decision not to follow the resident's plan of care and transfer her with 2 person assist". S2ADON was also requested to review two (2) documents entitled, "The Louisiana Nursing Home Malpractice and General Liability Trust I&A Reporting Forms". She confirmed there were a total of three (3) documented incident and accident reports in the month of November 2012 for resident #4 to include the incident of 11/23/12. Review of the other two (2) reports revealed the following documentation: 11/05/12: "Called to resident's room Resident with skin tear to L (Left) lower leg received transferring resident from beauty chair to w/c (wheelchair)". S2ADON was asked if this CNA performing the transfer was competent in transferring this resident. She stated she did not know. She was asked where was the investigation of this incident. S2ADON verified the back side of the form to document additional information was blank. S2ADON verified the form attached entitled, "Accident/Incident/Injury Investigation Form" was also blank. She was asked of an investigation was completed. S2ADON stated, "I do not know". 11/20/12: "Called to resident's room Resident with skin tear to R (Right) Lower leg origin unknown....." S2ADON was asked if this CNA performing the transfer was competent in transferring this resident. She stated she did not know. She was asked where was the investigation of this incident. S2ADON verified the back side of the form to document additional information was blank. S2ADON verified the form attached entitled, "Accident/Incident/Injury Investigation Form" was also blank. She was asked of an investigation was completed. S2ADON stated, "I do not know". Further review of the document entitled, "Treatment Record" Charting For 11/01/12 Through 11/30/12 for resident #4 revealed skin tears to resident #4 occurred on four (4) dates: 11/02/12, 11/05/12, 11/17/12, and 11/20/12. Further review of the Nurses Notes dated 11/24/12 at 9:30 a.m. for resident #4, the following day after resident #4 was transferred by one CNA (S15CNA) and sustained a right tibial fracture, revealed in part the following: .... "is complaining of some discomfort in Right ankle. Family members present in room- asked if MD would be coming by to look at resident's Right foot and leg. Assessment revealed some moderate swelling and cellular puffiness in right ankle and foot accompanied by some red-bluish discoloration. Resident does have a significant skin tear several inches above the foot on the mid-lateral aspect of the right leg".... On 12/18/12 at 2:00 p.m. an interview was conducted with S5CNASup. She was asked who were the CNAs assigned to resident #4 on the dates of the incident and accidents that occurred on 11/02/12, 11/05/12, 11/1712 and 11/20/12. She reviewed the Assignment Sheets and confirmed S16CNA was assigned to resident #4 on 11/02/12 and 11/05/12. S5CNASup. confirmed S15CNA was assigned to resident #4 on 11/17/12 and 11/20/12. S15CNA was the CNA that was fired after transferring resident #4 on 11/23/12 by herself resulting in resident #4 experiencing a fractured tibia, pain, and a decrease in her ADLs. On 12/18/12 at 3:15 p.m. an interview and record review was conducted with S1Adm. in the presence of S2ADON. S1Adm was asked to review the dates of the I&A Reporting Forms for resident #4. S1Adm confirmed there were three (3) I&A Forms for November 2012 and that (2) (11/05/12 and 11/20/12) were related to skin tears. S1Adm. also confirmed there was no investigation conducted regarding these accident / injuries. S1Adm was asked to review the November 2012 Treatment Record for resident #4. S1Adm. confirmed the documentation revealed resident #4 received four (4) skin tears on the following dates: 11/02/12, 11/05/12, 11/17/12, & 11/20/12 prior to her receiving a right tibial fracture on 11/23/12. S1Adm verified there were no I&A Forms completed for the skin tears resident #4 received on 11/02/12 & 11/17/12. S1Adm was informed at this time a further investigation by the surveyor revealed there were two CNAs that were assigned to this resident on the dates the skin tears occurred. She was also informed one of the CNAs was recently terminated due to causing the right tibia fracture on 11/23/12. S1Adm. was asked if an investigation should have been done for the skin tears to see if there was a problem to possibly identify trends for CNA proficiency. She verified an investigation should have been conducted for the skin tears. S1Adm. stated, "You made a good point". Findings: Resident #1 Review of the clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/17/12 at 11:55 a.m. the resident was observed sitting up in bed eating her lunch. She was asked how long had she been a resident at the facility. The resident stated "I'm not sure". She was asked how many staff assist her to get in and out of bed. The resident stated "one". Review of the Certified Nursing Assistant/ Activities of Daily Living Care Plan (CNA/ADL), posted inside the resident's closet door revealed the following transfer instructions: Two person assist, use total lift. High risks for falls. Review of the Minimum Data Set (MDS) Assessments, with Assessment Reference Dates (ARD) of 08/26/12 and 11/21/12, Section G, revealed the following: 08/26/12: Section G: Functional Status: Transfer: Support Provided: Two persons physical assist. Balance: moving from seated to standing: not steady, only able to stabilize with staff assistance; walking: activity did not occur; turning around: activity did not occur; moving on and off toilet: not steady, only able to stabilize with staff assistance; surface to surface transfer: not steady, only able to stabilize with staff assistance. 11/21/12: Section G: Functional Status: Transfer: Support Provided: Two persons physical assist. Balance: moving from seated to standing: not steady, only able to stabilize with staff assistance; walking: activity did not occur; turning around: activity did not occur; moving on and off toilet: not steady, only able to stabilize with staff assistance; surface to surface transfer: not steady, only able to stabilize with staff assistance. Review of the resident's care plan revealed the following: #1 Problem Onset: 10/19/09 Risk for Falls, Right Sided [MEDICAL CONDITION]. Goal & Target Date: Will have no injury related to falls during next 90 days: 06/08/12, 08/12/12, 11/12/12, 2/13/12. Approaches: Extensive assist needed for transfers and toileting with two staff. 03/04/12 eased to floor per CNA after becoming weak. 03/04/12 Reinforced staff 2 person assist with transfers sit to stand lift... 09/07/12 Slipped from side of bed. 09/07/12 CNA Counciled to always use a 2 person assist... #2 Problem Onset: 02/01/12 Potential for Injury Goal & Target Date: Will have no Injury Related to [MEDICAL CONDITION] Especially Fracture during next 90 days. 06/08/12; 08/12/12, 11/12/12, 02/13/12 Approaches: Staff Assist times two, with lift all transfers ... Review of the Fall Risk Assessments done on 10/20/12 and 11/21/12, revealed the resident scored 14, indicating she was " High risks for Falls " . Review of the facility's Incident & Accident Reporting Form, dated 09/07/12, revealed in part, the following: 4:00pm S13CNA was attempting to transfer resident from wheelchair to bed. Resident began to slip away from the CNA. S13CNA gently assisted resident to the floor. CNA received assistance transferring resident from the floor to the bed ..... No injuries noted.... Review of S13CNA's statement revealed in part, the following: When I was putting ______ in the bed I set her up on the side of bed and then she started to slip down on the floor so I laid her down on the floor and then I went in the hallway and I saw _____, CNA and I asked her to come and help me get _____ up from the floor and than once we got her up I went to tell the nurse what happened. Review of the facility's Fall Evaluation form revealed in part, the following: 09/07/12 4:00 p.m. Day of Week: Friday 2. Risk Factors: receives more than 5 medications, cardiovascular medications, diuretics. 3. Risk Factors: [MEDICAL CONDITIONS] Disorder, Diabetes, Vision Deficit, [MEDICAL CONDITION]. 4. Description of Fall: From wheelchair to bed. 11. Nurse's Account: S13CNA was transferring resident from wheelchair to bed and the resident began slipping away from CNA. CNA assisted resident to floor gently. CNA received assistance to transfer resident from floor to bed. On 12/18/12 at 2:00 p.m. an interview was conducted with S6LPN. After reviewing the incident & accident form dated 09/07/12, she verified S13CNA transferred the resident without assistance and without using the total lift. On 12/18/12 at 2:30 p.m. an interview was conducted with S2ADON. After reviewing the incident & accident form dated 09/07/12, she verified S13CNA transferred the resident without assistance and without using the total lift. On 12/18/12 at 12:40 pm an observation was made of S11CNA and S12CNA in the Hall "a" bathroom as they assisted Resident #1 to change her brief. The CNAs used a sit to stand lift to transfer the client from her wheelchair. They placed the standing sling behind the resident's back. There was a strap that encircled the resident's torso. This strap had a clasp to secure it in place. S11CNA and S12CNA did not secure the strap clasp leaving the sling hanging open on the resident. The resident was able to grip one of the lift handles with her (L) hand. Her right arm hung limp, as she has right sided [MEDICAL CONDITION]. S11CNA and S12CNA were asked why had they not secured the sling clasp across the resident's torso. Both CNAs stated they only secure the waist belt if the resident is unable to stand at all or is unable to hold on. They were asked if Resident #1 could stand or hold on to the lift. S11CNA and S12CNA verified the resident was paralyzed on her right side and unable to hold on to the lift with her right hand or stand on her right leg. Review of the facility's instructions for the use of the deluxe standing sling, from the manufacturer, revealed the following: Attach strap around the front of client. This strap need not be tight. It is there to hold the sling in position while attaching the sling to the Standaid. On 12/18/12 at 10:40 am an interview was conducted with S5CNASup. She was asked to review the CNA/ADL/ care plan posted on the inside of Resident #1's closet door. She was asked if this was the current care plan that the CNAs are to follow when providing care to the resident. S5CNASup stated "yes". She was asked if the resident required a two person assist for all transfers. S5CNASup stated "yes". She was asked if Resident #1 required the use of any sort of lift device. She stated " yes, we use the total lift on her ". S5CNA Sup further explained the total lift was a Hoyer lift with the "bed pad" used to transfer the resident. She was asked if the CNAs are ever to transfer this resident with the sit to stand lift device. She stated "no". She was asked if the staff are to secure the sling belt across the residents' torso when using the sit to stand lift. S5CNASup stated "yes". On 12/18/12 at 2:00 p.m. an interview was conducted with S6LPN. She was asked to review Resident #1's CNA/ADL/ care plan and the incident accident reporting form dated 09/07/12. She was asked if the resident required two persons assist for all transfers. S6LPN stated "yes". She was asked what type of lift device was required to transfer the resident. S6LPN stated "the total lift". She was asked if Resident #1 was an appropriate candidate for the sit to stand lift. S6LPN stated "no". She was asked if staff are to secure the sling belt across the residents' torso when using the sit to stand lift. S6LPN stated "yes". On 12/18/12 at 2:30 p.m. an interview was conducted with S2ADON. She was asked to review Resident #1's CNA/ADL/ care plan and the incident accident reporting form dated 09/07/12. She was asked if the resident required two persons assist for all transfers. S2ADON stated "yes". She was asked what type of lift device was required to transfer the resident. S2ADON stated "the total lift". She was asked if Resident #1 was an appropriate candidate for the sit to stand lift. S2ADON stated "no". She was asked if staff are to secure the sling belt across the residents' torso when using the sit to stand lift. S2ADON stated "yes". Resident #2 Review of the clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/18/12 at 8:45 a.m. an interview was conducted with the resident. She was asked how many staff assist her to get in and out of the bed. She stated "It takes two of them". The resident was asked if the staff ever use any type of equipment to get her out of the bed. She stated "they use that stand up thing". She went on further to state "when they use that stand up thing it only takes one person". Review of the Certified Nursing Assistant/ Activities of Daily Living Care Plan (CNA/ADL), posted inside the resident's closet door revealed the following transfer instructions: Two person assist. Review of the Minimum Data Set (MDS) Assessments, with Assessment Reference Dates (ARD) of 10/17/12; 11/19/12 and 11/25/12, Section G, revealed the following: 10/27/12: Section G: Functional Status: Section G: Functional Status: Transfer: Support Provided: Two persons physical assist. Balance: moving from seated to standing: not steady, only able to stabilize with staff assistance; walking: activity did not occur; turning around: activity did not occur; moving on and off toilet: not steady, only able to stabilize with staff assistance; surface to surface transfer: not steady, only able to stabilize with staff assistance. 11/19/12: Section G: Functional Status: Transfer: Support Provided: Two persons physical assist. Balance: moving from seated to standing: not steady, only able to stabilize with staff assistance; walking: activity did not occur; turning around: activity did not occur; moving on and off toilet: not steady, only able to stabilize with staff assistance; surface to surface transfer: not steady, only able to stabilize with staff assistance. 11/25/12: Section G: Functional Status: Transfer: Support Provided: Two persons physical assist. Balance: moving from seated to standing: not steady, only able to stabilize with staff assistance; walking: activity did not occur; turning around: activity did not occur; moving on and off toilet: not steady, only able to stabilize with staff assistance; surface to surface transfer: not steady, only able to stabilize with staff assistance. Review of the resident's care plan revealed the following: #1 Problem Onset: 09/28/12 Requires Assistance with ADLs ... Goal & Target Date: Will have needs/wants met through next 90 days. 12/28/12 Approaches: Requires extensive 2 person assist with transfers ...total dependence with two person assist for transfers. #2 Problem Onset: 09/28/12 Risks for Falls related to personal history of falls, chair bound, decreased muscular coordination ... Goal & Target Date: Will have no injury from falls through the next 90 days (12/28/12) Approaches: Assess Resident after each fall for causes and interventions ... Problem Onset: 10/19/12 Resident to floor by CNA Approaches: Transfer X 2 person assist Review of the resident's Fall Risk Assessments revealed the following: 09/25/12: Score 14/High Risk; 10/10/12: Score 14/High Risk; 10/19/12: Score 12/High Risk; 11/13/12: Score 14/High Risk. On 12/18/12 at 12:40 p.m. interview conducted with S11CNA and S12CNA, who were working on Hall "a" where Resident #2 resides. They were asked what was the procedure for transferring Resident #2. Both S11CNA and S12CNA stated the resident was a 2 person assist with the sit to stand lift. They were asked how do they know what type of transfer the residents require. S11CNA and S12CNA stated they look at the CNA/ADL/care plan posted inside the residents closet doors. Resident #3's ADL/CNA/care plan posted inside her closet door list 2 person assist for transfers, there is no instruction to use the sit to stand lift. On 12/18/12 at 10:40 a.m. an interview was conducted with S5CNASup. She was asked to review the CNA/ADL/ care plan posted on the inside of the resident's door. She was asked if this was the current care plan that the CNAs are to follow when providing care to Resident #2. She stated "yes". She was asked if staff were to use any sort of lift device to transfer the resident. She stated "no". On 12/18/12 at 2:00 p.m. an interview was conducted with S6LPN. She was asked to review Resident #2's CNA/ADL/ care plan and the nursing care plan. She was asked if the staff were to use any sort of lift device to transfer the resident. She stated "no". On 12/18/12 at 2:30 p.m. an interview was conducted with S2ADON. She was asked to review Resident #2's CNA/ADL/ care plan and the nursing care plan. She was asked if the staff were to use any sort of lift device to transfer the resident. She stated "no". Resident #3 Review of the clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/17/12 at 1230 p.m. the resident was observed sitting in a specialized supportive wheelchair with a self release seat belt on, in the Hall "b" day area. The resident was awake but did not respond verbally when asked questions. Review of the Certified Nursing Assistant/ Activities of Daily Living Care Plan (CNA/ADL), posted inside the resident's closet door revealed the following transfer instructions: Two person assist, Use Total Lift. Review of the Minimum Data Sets with Assessment reference Dates of 05/22/12; 10/22/12 and 11/11/12 revealed the following: 10/20/12: Section G: Section G: Functional Status: Transfer: Support Provided: Two persons physical assist. Balance: Moving from seated to standing, walking, turning around, moving on and off toilet, surface to surface transfer: activity did not occur. 11/11/12: Section G: Functional Status: Transfer: Support Provided: Two persons physical assist. Balance: Moving from seated to standing, walking, turning around, moving on and off toilet, surface to surface transfer: activity did not occur. 11/11/12: Section M: Skin Conditions: G. Skin Tears (checked). Review of the resident's care plan revealed the following: #1. Problem Onset: 07/07/10: Potential for impaired skin integrity, incontinent of B&B. Goal & Target dates: Will maintain optimal integrity over the next 90 days. Approaches: Handle with care; 2 staff for bed mobility; cushion in wheelchair #2. Problem Onset: 10/28/12 Skin tear to top of (L) hand Goal: will show signs of improvement within the next 90 days. Approach: Medical Doctor notified, clean with normal saline solution, pat dry, cover with dry dressing to be changed daily. #3. Problem onset: 07/07/11 At risks for falls Goal & Target Dates: Will have no injury resulting from fall within next 90 days. Approaches: Staff assist X 2. .... Review of the facility's Incident & Accident Reporting Form, dated 10/28/12, revealed the following: Resident was being transferred from a special supportive wheelchair back to bed by 2 attendants when the attendants laid her down they noticed bright red bleeding from the top of (L) hand. Assessment shows a fresh skin tear 5.5 cm long straight line tear with edges intact top of (L) hand. Resident must have bumped hand against turned up side rail in the transfer. 1st aid given with cleansing normal saline-pat dry-applying 10 micro steri-strips to hold edges together until adherence. Dry bandage applied and covered, daily observation to be done. Review of the facility's Accident/Incident/injury Investigation form revealed the following: CNAs were transferring resident back to bed from special supportive wheelchair when after they got resident into bed,they observed fresh bleeding on top (L) hand-called nurse____ to come assess and treat. Interventions to help prevent possibility of reoccurrence: Take more caution when transferring residents-more time to size up and position self and the resident before actual transfer. Review of the resident's Fall Risks Assessments revealed the following: 05/22/12 Score 14/High Risk; 05/30/12 Score 14/High Risk; 08/10/12 Score 14/High Risk; 08/22/12 Score 10/High Risk; 08/28/12 Score 14/High Risk; 09/04/12 Score 14/High Risk; 09/19/12 Score 15/High Risk On 12/18/12 at 10:40 a.m. an interview was conducted with S5CNASup. She was asked to review the CNA/ADL/ care plan posted on the inside of the resident's closet door. She was asked if this was the current care plan that the CNAs are to follow. She stated"yes". She was asked if the resident required a two person assist for all transfers. She stated "yes". She was asked if Resident #3 required the use of any sort of lift device. S5CNASup stated 'yes, we use the total lift on her". She was asked if the CNAs are ever to transfer this resident from bed to chair and back without the use of the total lift. S5CNASup stated "no'. On 12/18/12 at 2:00 p.m. an interview was conducted with S6LPN. She was asked to review Resident #3's CNA/ADL/ care plan and the nursing care plan. She was asked if the staff were to ever transfer the resident without the use of the total lift. She stated "no". On 12/18/12 at 2:30 p.m. an interview was conducted with S2ADON. She was asked to review Resident #3's CNA/ADL/ care plan and the nursing care plan. She was asked if the staff were to ever transfer the resident without the use of the total lift device. She stated "no". On 12/18/12 at 11:40 a.m. an interview was conducted with S10CNA, working on Hall "b", where Resident #3 resided. She verified she and S14CNA transferred the resident from her wheelchair to her bed on 10/28/12. She was asked how was Resident #3 to be transferred. S10CNA stated "with 2 people". She was asked if the resident required a lift device. S10CNA stated "no". She was asked if the a lift device was used on 10/28/12 when she and S14CNA transferred the resident from her wheelchair to her bed. She stated "no". She was asked how did she think the resident got the skin tear. She stated " I'm not sure cause I didn't see it happen but it might have bumped the bed rail ". She was asked how does she get information regarding the needs/care of residents. S10CNA stated there is a book at the nurses' station with the information. She was asked if there was anything posted in the residents rooms to guide the staff on the care to be provided. S10CNA stated "no".

Based on observations, interviews and record reviews the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 (Resident #4) of 5 (#1, #2, #3, #4, #5) sampled residents reviewed by failing to: 1) provide the necessary transfer assistance for a resident requiring two person assistance; 2) provide services according to the resident's plan of care; 3) ensure resident #4 did not experience a decline in Activities of Daily Living; 4) conduct an investigation after resident #4 received several skin tears and determine the causes of the skin tears; 5) ensure resident #4 did not experience additional pain; and 6) ensure resident #4 did not experience a decline in her psychosocial well-being. Resident #4 was admitted to the facility on [DATE] for rehabilitation following hip surgery after falling at home. Upon admission to the facility, she required two persons to transfer and was transferred by one Certified Nursing Assistant on 11/23/12. Resident #4 sustained a right tibia fracture following this transfer that resulted in immobility, a decline in several of her Activities of Daily Living, increased pain medication, and a decrease in her psychosocial well-being. Findings: On 12/17/12 a record review was conducted for resident #4. She was admitted to the facility on [DATE]. Review of the History and Physical prior to admission to the facility dated 09/16/12 revealed she was [AGE] years old and lived alone at home. Documentation revealed, "According to the family, she has mild dementia but typically ambulates in her house alone with a walker". Further review of the History and Physical revealed she was found at home, alert and oriented, lying on her right hip and complained of right hip pain. She was taken to a local emergency room and was found to have a right intertrochanteric [MEDICAL CONDITION]. Resident #4 was transferred to another hospital and underwent an Open Reduction Internal Fixation (ORIF) surgical procedure for her right [MEDICAL CONDITION]. Review of the History and Physical dated 09/24/12 dictated by resident #4's nursing home attending physician revealed in part the following: "..... she was stable and transferred to the nursing home for rehabilitation". Review of the Physical Therapy Plan of Care upon admission to the facility dated 09/21/12 revealed in part the following: Reason for Referral: Recent fall / hip fx (fracture) / hospitalization resulting in decrease in strength, balance, endurance, and safety. Therapy Necessity: Therapy necessary to increase functional mobility. "Without therapy, patient at risk for illness and/or injury due to decreased mobility". Prior Residence and Living Arrangement: Patient lived at home with part time sitters and required assistance from sitters/home health for advanced ADLs (Activities of Daily Living) such as bathing, meal prep, some dressing, and transportation. Precautions: NWB (Non Weight Bearing) RLE (Right Lower Extremity) Review of the document entitled, "Minimum Data Set (MDS) - Version 3.0 For Nursing Home Resident Assessment and Care Screening" Assessment Reference Date (ARD): 09/28/12 (7 days following admission to the facility) revealed in part the following: Section G - Functional Status Transfer- self-performance: Total dependence - full staff performance every time during entire 7-day period. Transfer- support provided: "Two+ persons physical assist". Review of the Care Plan revealed in part the following two problems identified for resident #4 upon admission: 1) Problem Onset: 09/21/12 Requires Assistance With ADLs Approaches included: PT (Physical Therapy) / OT(Occupational Therapy) / ST(Speech Therapy) to eval (evaluate) and treat pt (patient) as indicated. Max (Maximum) assist with bathing. Max assist with toileting. Max assist with transfers. 2) Problem Onset: 09/21/2012 Potential for Pain Related to Right [MEDICAL CONDITION] Approaches included: Medications as ordered: [MEDICATION NAME] prn (as needed), Tylenol prn Further review of the C.N.A. (Certified Nursing Assistant) ADL (Activities of Daily Living) Plan of Care dated 10/18/12 revealed in part the following: "Transfer Skills Two Person Assist". On 12/17/12 at 9:30 a.m. an observation and interview was conducted with resident #4 and S3Sitter in resident #4's room. S3Sitter verified she was resident #4's sitter. She stated she had known this resident a long time. She stated this resident was her 2nd grade teacher. Resident #4 stated and verified she was a school teacher. S3Sitter was asked why this resident was admitted to the nursing home. She stated she fell at home and broke her hip. She stated she was receiving therapy at the nursing home and was doing much better until her right leg was broken. When asked what happened to her right leg she stated, "A new CNA was transferring her from the wheelchair to the bed and didn't transfer her correctly". S3Sitter stated, (resident #4) will stiffen up when you try to stand her. She stated this CNA had resident #4 close to the bed and hit her right leg on the bed and broke it. She stated resident #4 told the CNA, "You hurt me". S3Sitter stated, "This CNA transferred resident #4 by herself". She stated she did not know why this CNA transferred her by herself because resident #4 required two persons to transfer. She stated she noticed something was wrong after this CNA transferred resident #4. S3Sitter stated resident #4's right lower leg became warm and swollen and started to complain of pain on Friday, 11/23/12. S3Sitter was asked if she remembered the name of the CNA who transferred resident #3 and broke her leg. She stated she did not remember her name. She was asked if she witnessed the CNA transferring resident #4. She verified she did. Review of a document entitled, "Louisiana DHH (Department of Health and Hospitals) Client Incident Report" Incident ID: revealed in part the following documented evidence: Victims (Resident #4) Case Notes Description: "Resident right lower leg noted to be warm, slightly [MEDICAL CONDITION] on Friday evening, 11/23/2012. Attempted to contact physician for orders, no response received. On Saturday, 11/24/2012, nurse noted that right lower leg was grossly [MEDICAL CONDITION] and discolored. Contacted physician and new order received to send to ER (emergency room ) for eval (evaluation). 3:30 pm resident returns to facility with [DIAGNOSES REDACTED].. Currently under care of PT/OT services for status [REDACTED]. Attached to the Client Incident Report revealed a written statement from S3Sitter documenting the following: "At 2:15 p.m. Friday, Nov. 23, CNA came in to transfer (resident #4) from wheelchair to bed. She was by herself... (Resident #4) right leg did not turn because she was stiff. (Resident #4) yelled you hurt me". On 12/17/12 at 12:15 p.m. an interview was conducted with S4PT. She was asked to describe resident #4's functional status upon admission to the facility. She stated resident #4 was NWB (Non Weight Bearing) on her right leg due to having recent hip surgery. She stated resident #4 was unable to ambulate and required maximum assistance to transfer upon admission. When asked if resident #4 improved with therapy she stated yes. She stated resident #4 progressed and was able to bear weight on her right leg on 10/26/12. S4PT was asked what was her current functional status following the incident that occurred on 11/23/12 when resident #4 fractured her tibia. S4PT stated, "Her functional status has declined". She stated, "After 11/23/12 she became non weight bearing again". She stated resident #4 was able to tolerate being up in the wheelchair or sit in her recliner for extended periods of time prior to this incident. She stated, "She only gets up out of bed now with therapy". Review of the PT Daily Treatment Notes dated 11/22/12, one day prior to resident #4 receiving a fractured tibia at the facility, confirmed resident's functional status improved to moderate assistance from supine position to sitting position and moderate assistance to transfer from the bed to a wheelchair. Review of the PT Daily Treatment Notes dated 11/26/12 confirmed resident #4 was immobile and was experiencing a decrease in her psychosocial well-being: "Pt presented supine in bed with RLE (Right Lower Extremity) wrapped and on pillows into neutral knee flexion/extension. Pt upset that she 'has wronged God, and He is punishing her' with recent RLE fracture".... On 12/17/12 at 3:10 p.m. an interview was conducted with S5CNASup. She was asked if she was aware of the incident that occurred on 11/23/12 when resident #4's right tibia was fractured. She stated, "I think it happened over a weekend and I was not here". She stated when she came back on Monday she was told by the nurse or Director of Nurses that her leg was broken during a transfer. She stated S15CNA transferred resident #4 by herself and lied about it. She stated the facility disciplined this CNA and she was fired for lying. S5CNASup. was asked to review the C.N.A. ADL Plan of Care dated 10/18/12. S5CNASup. confirmed resident #4 required two persons for transfers. Following the incident on 11/23/12 when resident # 4 was transferred by one CNA sustaining a right tibia fracture, resident #4 experienced a decline in bed mobility, transfer, locomotion both on and off the unit, dressing, eating, personal hygiene, bathing, balance, mobility, and her psychosocial well-being. Review of the MDS Significant change in status assessment ARD 12/01/12 confirmed resident #4 experienced a decline compared to the prior MDS Admission Assessment ARD 09/28/12 as documented under Section G - Functional Status in both MDS Assessments below: Bed Mobility- self-performance: Total Dependence (prior assessment extensive assistance) Bed Mobility- support provided: Two+ persons physical assist (prior assessment one person physical assist) Transfer- self-performance: activity did not occur (prior assessment total dependence) Transfer- support provided: ADL activity itself did not occur (prior assessment two+ persons physical assist) Locomotion on unit- self-performance: Activity did not occur (prior assessment limited assistance) Locomotion on unit- support provided: ADL activity itself did not occur (prior assessment one person physical assist) Locomotion off unit- self-performance: Activity did not occur (prior assessment limited assistance) Locomotion off unit- support provided: ADL activity itself did not occur (prior assessment one person physical assist) Dressing- self performance: Total Dependence (prior assessment limited assistance) Dressing- support provided: Two+ persons physical assist (prior assessment one person physical assist) Eating- self performance: limited assistance (prior assessment supervision) Eating- support provided: One person physical assist (prior assessment setup only) Personal Hygiene- self-performance: Total dependence (prior assessment limited assistance Bathing- self-performance: Total dependence (prior assessment physical help in part of bathing activity) Bathing- support provided: Two+ persons physical assist (prior assessment one person physical assist) Balance- moving from seated to standing position: Activity did not occur (prior assessment not steady, only able to stabilize with staff assistance) Balance- moving on and off toilet: Activity did not occur (prior assessment not steady, only able to stabilize with staff assistance) Balance- surface to surface transfer: Activity did not occur (prior assessment not steady, only able to stabilize with staff assistance) Mobility devices- wheelchair was unchecked (prior assessment was checked) Resident believes capable of increased independence: "BLANK" (prior assessment "Yes"). On 12/17/12 at 3:35 p.m. an interview and record review was conducted with S6LPN. She verified she was one of the MDS nurses and verified she conducted both MDS Assessments for resident #4. She was asked how did she perform the assessment for Section G - Functional Status. She reviewed Section V - Care Area Assessment of the MDS Significant change in status assessment with the surveyor. Review of Section V confirmed her assessment was a review of the Nurses Notes dated 11/24/12 - 12/01/12. S6LPN was asked if resident #4 experienced a decline in her functional status compared to the Admission Assessment of 09/28/12. S6LPN stated, "She experienced a decline in bed mobility and locomotion on/off the unit". She stated resident #4's assistance with eating also declined due to the pain medication making her sleepy. She was asked if resident #4's ADLs declined due to the incident that occurred on 11/23/12 when resident #4 was transferred by one CNA and sustained a fracture to her right tibia. S6LPN stated, "Yes". Further review of the Care Plan revealed the following revisions to the care plan due to resident #4 sustaining a fractured right tibia on 11/23/12: Problem Onset: 09/21/2012 Requires Assistance with ADLS Updated Approach: 11/24/12 Non weight bearing to right leg until seen by (name of physician). Problem Onset: 09/21/12 Potential for Pain Related to Right [MEDICAL CONDITION] Updated Problem: 11/24/12 Right Tibia Fracture Updated Approaches: 11/24/12 [MEDICATION NAME] (narcotic medication used to relieve moderate to severe pain) 7.5/325 (1) tab (tablet) q (every) 4-6 hrs (hours) prn (as needed) pain. 11/24/12 Keep leg elevated. 11/24/12 Do not bear weight on injured leg until cleared by Dr to do so. 12/13/12 MD (Doctor) appt. (appointment) with (name of doctor) Plan. Knee immobilizer to Right leg. Transfer OOB (out of bed) in chair NWB (Non Weight Bearing) Right leg with Physical Therapy. F/U (Follow up) in 4 weeks. Will x-ray then. Review of the Medication Administration Records and Nurses Notes dated 11/25/12 - 12/13/12 revealed resident #4 required sixteen (16) doses of the narcotic [MEDICATION NAME] to relieve the pain of her right tibia fracture. Resident #4 also required the medication [MEDICATION NAME], a stool softener, every night beginning 11/26/12 due to her immobility and receiving the narcotic pain medication. On 12/18/12 at 10:10 a.m. an interview and record review was conducted with S2ADON. She was asked to review the Nurses Notes documentation dated 11/23/12 the night of the injury to resident #4's right leg. Review of the Nurses Note revealed the following: "Pt. (Patient) lying in bed in bed in supine position AAOX3 (Awake, Alert, Oriented times 3) no c/o (complaints), no s/s (signs and symptoms) of pain or discomfort, tolerated meds well, will continue to monitor". She was asked if this nurse continued to assess resident #4's lower right leg following the injury that occurred earlier that day. S2ADON confirmed and verified there was no documented evidence of a visual assessment of resident #4's lower right leg. S2ADON was also asked to review the employee record of S15CNA. She verified S15CNA was accused of transferring resident #4 by herself on 11/23/12. She reviewed S15CNA's employee file and confirmed this record contained documented evidence of a Nursing Assistant Competency Check List for transfers completed on 11/01/12. She was asked if S15CNA was able to demonstrate competency as identified in resident #4's assessments and plan of care. S2ADON stated "This CNA made a bad decision not to follow the resident's plan of care and transfer her with 2 person assist. S2ADON was requested to review two (2) documents entitled, "The Louisiana Nursing Home Malpractice and General Liability Trust I&A Reporting Forms". She confirmed there were a total of three (3) documented incident and accident reports in the month of November 2012 for resident #4 to include the incident of 11/23/12. Review of the other two (2) reports revealed the following documentation: 11/05/12: " Called to resident's room Resident with skin tear to L (Left) lower leg received transferring resident from beauty chair to w/c (wheelchair)". S2ADON was asked if this CNA performing the transfer was competent in transferring this resident. She stated she did not know. She was asked where was the investigation of this incident. S2ADON confirmed the back side of the form to document additional information was blank. S2ADON confirmed the form attached entitled, "Accident/Incident/Injury Investigation Form" was also blank. She was asked if an investigation was completed. S2ADON stated, "I do not know". 11/20/12: "Called to resident's room Resident with skin tear to R (Right) Lower leg origin unknown....." S2ADON was asked if this CNA performing the transfer was competent in transferring this resident. She stated she did not know. She was asked where was the investigation of this incident. S2ADON confirmed the back side of the form to document additional information was blank. S2ADON confirmed the form attached entitled, "Accident/Incident/Injury Investigation Form" was also blank. She was asked if an investigation was completed. S2ADON stated, "I do not know". Further review of the document entitled, "Treatment Record" Charting For 11/01/12 Through 11/30/12 revealed resident #4 sustained skin tears on the following dates: 11/02/12, 11/05/12, 11/17/12, and 11/20/12. There was no documented evidence of an Incident and Accident Reporting Form for 11/02/12 and 11/17/12. On 12/18/12 at 2:00 p.m. an interview was conducted with S5CNASup. She was asked who were the CNAs assigned to resident #4 on the dates of the incident and accidents that occurred on 11/02/12, 11/05/12, 11/1712 and 11/20/12. She reviewed the Assignment Sheets and confirmed S16CNA was assigned to resident #4 on 11/02/12 and 11/05/12. S5CNASup. confirmed S15CNA was assigned to resident #4 on 11/17/12 and 11/20/12. S5CNASup. verified S15CNA was the CNA who transferred resident #4 on 11/23/12 by herself resulting in resident #4 sustaining a fractured tibia. On 12/18/12 at 3:15 p.m. an interview and record review was conducted with S1Adm. in the presence of S2ADON. S1Adm was asked to review the dates of the I&A Reporting Forms for resident #4. S1Adm confirmed there were three I&A Forms for November 2012 and that two (11/05/12 and 11/20/12) were related to skin tears. S1Adm. also confirmed there was no investigation conducted regarding these accident / injuries. S1Adm was asked to review the November 2012 Treatment Record for resident #4. S1Adm. confirmed the documentation revealed resident #4 received four skin tears on the following dates: 11/02/12, 11/05/12, 11/17/12, & 11/20/12 prior to her receiving a right tibia fracture on 11/23/12. S1Adm verified there were no I&A Forms completed for the skin tears resident #4 received on 11/02/12 & 11/17/12. S1Adm was informed at this time a further investigation was conducted by the surveyor and revealed there were two CNAs assigned to resident #4 on the dates the skin tears occurred. She was also informed one of the CNAs was terminated due to transferring resident #4 by herself and causing the right tibia fracture on 11/23/12. S1Adm. was asked if an investigation should have been done for the skin tears to see if there was a problem to possibly identify trends for CNA proficiency. She verified an investigation should have been conducted for the skin tears and stated, "You made a good point".